A GUIDE 



TO THE 



Diseases of Children 



THE WORKS OF LOUIS STARR, M.D. 



THE DISEASES OF THE DIGESTIVE ORGANS IN 
INFANCY AND CHILDHOOD, with Chapters on the In- 
vestigation of Disease and the Management of Children. Illus- 
trated. 8vo. $2.50. 

THE HYGIENE OF THE NURSERY, including the General 
Regimen and Feeding of Infants and Children. Illustrated. 
Second Edition. 12010. Cloth, $1.00. 



A GUIDE 



Diseases of Childre 



N 



JAMES FREDERIC GOODHART, M.D., F.R.C.P., 

PHYSICIAN TO GUY'S HOSPITAL, AND LECTURER ON PATHOLOGY IN ITS MEDICAL SCHOOL 

PHYSICIAN TO THE EVELINA HOSPITAL FOR SICK CHILDREN. 



rt REARRANGED, REVISED AND EDIT 



^ 



(3 



LOUIS STARR, M.D. 




CLINICAL PROFESSOR OF DISEASES OF CH ILDREN IN THE HOSPITAL OF TH E UNIVERSITY OF 
PENNSYLVANIA; PHYSICIAN TO THE CHILDREN'S HOSPITAL, PHILADELPHIA, ETC. 



SECOND AMERICAN, FROM THE THIRD ENGLISH EDITION. WITH 
NUMEROUS FORMULAE AND ILLUSTRATIONS. 



PHILADELPHIA: 

P. BLAKISTON, SON & CO., 

1012 Walnut Street. 
1889. 






Copyrighted, 1889, by P. Blakiston, Son & Co. 



PRESS OF WM. F. FELL 4 CO., 

1*20-24 SANSOM STREET, 

PHILADELPHIA. 



PREFACE TO THE 
SECOND AMERICAN EDITION. 

In preparing the second American edition of Dr. Good- 
hart's work, the Editor has taken the liberty of re-arranging 
the original matter so as to secure greater symmetry and 
ease of reference. In doing this especial care has been 
employed to alter, in the least possible degree, the author's 
forcible descriptions of disease, and to preserve a feature, 
possessed by the first edition and highly praised by Ameri- 
can reviewers, namely, the close resemblance of the text to 
actual bedside teaching. The brackets ([ ]) originally sur- 
rounding the suggestions of the Editor have been omitted, 
as he believes his additions to be in the spirit of the 
author's writing and entirely in accord with his views. 

The subject of " Feeding infants and children " has been 
greatly elaborated, and this important question, together 
with the whole of the work, brought thoroughly abreast 
with the recent advance in pediatric science. 

The insertion of typical temperature charts is a new fea- 
ture in works on children's diseases, but remembering the 
need of such graphic representations of thermic ranges in 
his early years, the Editor hopes by their use to help the 
student and junior practitioner. 

The many admirable su^o-estions of the reviewers of the 
first edition have been treated with due respect, and their 
hints must claim a share in whatever improvement there 
may be in this second venture. 

The Editor also wishes to acknowledge his indebtedness 
to Dr. W. M. Powell for his most efficient aid in the prepa- 
ration of the copy and index. 

Louis Starr. 

1818 S. RitteiiJiouse St/., Philadelphia, Xov., 1889. 

V 



PREFACE TO 
SECOND ENGLISH EDITION. 

The present edition has been thoroughly revised, and some 
slight but important additions and re-arrangements made, 
which will, I think, enhance the value of the book. Not 
least of these is a much more copious index, which has been 
in great part compiled by Mr. C. H. Wells, and which 
deserves a full acknowledgment. In several places hints 
have been obtained from the American edition, which has 
been brought out under the able and sympathetic guid- 
ance of Dr. Louis Starr, Physician to the Children's Hos- 
pital, Philadelphia. Full consideration has also been given 
to such criticisms as have reached me. But in truth these 
have been so few and kindly, and the sale of the work has 
been so rapid, that but little suggestion for revision has 
been thus derived. It is a pleasure to add that in this, as in 
the former edition, the experience, the sound judgment and 
active interest of my friend Dr. Lewis Marshall, of the Not- 
tingham Hospital for Children, have been of the utmost 
help to me. 

James F. Goodhart. 

August, j 8 86. 



VI 



PREFACE TO 
THIRD ENGLISH EDITION. 

The present edition has been revised throughout, but has 
undergone no material alteration. Some slight re-arrange- 
ment has been made in the earlier chapters, and I have 
endeavored to make it more useful to the student and young 
practitioner by amplifying the directions relating to diet in 
infancy, and generally by inserting, where possible, such 
recent methods of treatment as have either proved, or 
promise to be, successful. 

James F. Goodhart. 

Septei7iber, 1888. 



Vll 



CONTENTS 



PAGE 

Introduction, 13 

PART I. 
Diseases of the Digestive System, 51 

PART IT. 

Acute Infectious Diseases, . . ■ 193 

PART III. 
General Diseases not Infectious, 343 

PART IV. 
The Diathetic Diseases, 393 

PART V. 
Diseases of the Spleen and Blood, , . . . 431 

PART VI. 
Diseases of the Nervous System, 445 

PART VII. 
Diseases of the Organs of Respiration, 579 

PART VIII. 
Diseases of the Heart, 681 

PART IX. 
Diseases of the Genito-Urinary Organs, 709 

PART X. 
Diseases of the Skin, 7 2 7 



Vlll 



THE 

DISEASES OF CHILDREN 



INTRODUCTION. 

What is a child, and how the diseases of children differ 
from the diseases of adult life, are questions which must 
have confronted all who have written upon the ailments of 
childhood, and not a little puzzled them for an answer. By 
the pathologists, indeed, it may well be doubted if any valid 
reason can be given for making a separate group of the 
diseases of children, for there are but few morbid changes 
found in childhood that are not to be seen at one time or 
another in the bodies of adults. 

If we run over the various regions of the body, the brain, 
heart, lungs, lymphatic glands and so on, few, and those 
but minor, differences can be pointed out between the pro- 
ducts of disease in a child and of the same disease in an 
adult. Some diseases are more common at one time of life 
than at the other ; but should they overstep the limit of age 
usual to them, they appear in their old form, or with but 
slight modifications, such as would certainly not justify any 
one in devoting a " manual " to their description. 

The bones form the most notable exception to this rule : 
in rickets, acute ostitis, and some forms of enchondroma we 
have examples of constancy of peculiarity of morbid deposit ; 
2 13 



14 DISEASES OF CHILDREN. 

of constancy of limitation to the growing age ; of constancy 
of peculiarity of distribution of the disease, and so on. Cer- 
tain diseases of the skin and teeth might equally be advanced, 
but having said even this, we should still be at fault for 
material for a book. The difficulties and differences which 
render it advisable that these diseases should receive special 
study are mostly those of semeiology and treatment, and 
from the fact that the student, when first introduced to this 
branch of practice, finds himself thrown upon his own re- 
sources. In the adult he can ask questions and obtain clues 
to the furtherance of his diagnosis. With infants and chil- 
dren he must find out what he can for himself — the history 
is faulty or often quite wanting — and here he fails. For 
instance, it is a common occurrence in hospital practice to 
find that no account is forthcoming from the clinical clerk 
of some child that has been admitted since the last visit. 
He has not yet seen the mother, is the explanation offered 
for the omission. Supposing,' now, that we change the 
venue, so to speak, of this illustration to that of the veteri- 
nary surgeon, and one of the lower animals, and such an 
answer, were it conceivably possible, would be ludicrous. 
Yet, there is not so very much difference between the stu- 
dent who has to investigate the diseases of children and one 
who has to do with diseases of the lower animals. In both 
cases the diagnosis will chiefly rest upon the doctor's own 
observation and examination. In both intelligible speech 
is wanting. Any history that a parent or a relative can 
give, is by no means to be underrated ; on the contrary, an 
intelligent mother and nurse are to be listened to patiently 
and attentively — they are often acute observers of early 
signs of ill health, or changes in the symptoms. What is 
important to enforce is, that the previous history occupies 
a subordinate, not the chief, position, and the student is at 
all times to consider himself as independent of it. Any 



INTRODUCTION. 1 5 

help that can be obtained in this way is all well and good, 
but it is secondary to a personal examination. 

Supposing, now, that a child is before us, what is to be 
done in making a thorough examination ? Our first care 
will be not to frighten the child, a task which at once calls 
into play tact, patience, and control of feeling. A strange 
face is alone sufficient to make a child cry, but when that 
face belongs to the doctor, a word very early added to the 
child's small repertory, and when these are associated 
indelibly with memories of castor-oil or other bad-tasting 
medicine, inexperienced nature can hardly be expected not 
to revolt — and revolt it often does, regardless sometimes of 
the most exquisite tact. But much can be done to soothe 
matters by the expenditure of a little trouble ; never be in 
a hurry ; take time, that the child may become accustomed to 
you ; talk to it, play with it, and show it any glittering thing 
that may be at hand. A stethoscope or other instrument that 
it maybe necessary to use should first be made a plaything, 
the subsequent examination being often much facilitated by 
so doing. Do not touch a child till it has had a good look 
at you. Plenty of occupation is afforded in the meantime 
in questioning the mother or nurse. Then, with regard to 
special instruments, the thermometer, for instance, which is 
constantly in use, put it into the axilla and hold it there 
gently, with your eye on the column of mercury, talking to 
the child all the while, and even drawing its attention to it. 
If the forearm be not restrained, it will be possible to do this 
for a minute or two, during which you may watch the mer- 
cury quickly rise to a certain height, and then proceed more 
leisurely. If the child become restless, withdraw it ; the 
half degree or so which it may rise afterward will be of 
little importance to you in drawing conclusions, whereas a 
fit of crying or any fright will render all further observa- 
tions difficult. In infants, however, it is best to take the 



1 6 DISEASES OF CHILDREN. 

temperature in the rectum, since the surface heat varies 
greatly with that of the surrounding atmosphere, and since 
it is difficult to maintain quiet long enough for an axillary- 
observation. The well-oiled bulb of a thermometer should 
be gently inserted through the anus, and kept in place for 
three minutes. The normal temperature in this position is 
from i° to 2° higher than in the axilla. The temperature 
may also be taken in the groin or between the scrotum or 
labium and thigh ; the reading will not be so high as in the 
axilla, and of course much lower than in the rectum. In 
older children, the mouth is a very convenient and certain 
locality for observation ; here the normal reading is at 
least i° higher than in the arm-pit. Some of the peculiari- 
ties of the temperature in infancy will be referred to later. 

With the ophthalmoscope again try to get the child to 
consider the instrument a toy, the examination a game 
of play, and — with plenty of patience, for a child's eye par- 
takes of the restlessness of its whole muscular system, and 
no fixed look at any object, however attractive, can be 
counted upon for more than a second or two — there are few 
children or infants in whom the optic disks cannot be seen. It 
is essential to success in some cases not to touch the child. 
As soon as a finger is placed on the forehead to steady the 
lens used for the indirect method, many a child will rebel. 
The same remark applies still more forcibly to pulling up 
the upper lid to obtain a view of the pupil. The attention 
must be attracted by playing the light on and off the eye ; 
and skill will come with practice in ascertaining the state of 
the fundus by repeated momentary glimpses rather than by 
any one prolonged view. Even the hsemacytometer, for 
which it is necessary to prick the finger, may be used with- 
out making a child cry, by making a rapid prick with a 
needle and showing the resulting drop of blood to the child 
as a wonderful thing. To make a rule, the child is to be 



INTRODUCTION. 1 7 

restrained as little as possible in any examination that may 
be necessary. The mother or nurse will often hold its 
hands or. its legs, or both, as the first step to auscultation, 
and there is nothing which a child resists more than restraint 
of this kind. Let it kick about, if it will, till it becomes 
unmanageable, and this will but seldom be the case if we 
take care not to make it so. Let it play with the end of the 
stethoscope, if it likes ; it is quite possible to distinguish the 
respiratory sounds, and after a time those of extraneous 
origin can be as readily ignored as can the noise made by 
a crying child. The fact that the child is crying is no 
excuse for not examining the chest — crying necessitates 
deep respiration, and is often advantageous for this reason. 
All that we need is more patience. In auscultation, also, 
it is often necessary to listen to the respiratory or heart 
sounds in snatches, and to fill in by repeated observations 
what is not permitted by continuous examination ; and in 
many cases it is advisable to examine the back of the chest 
first. 

Having given these few hints upon what to avoid, a few 
may follow concerning what has to be done — and first we 
must be careful to maintain an attitude of close observation. 
The points to be observed are often apparently trivial and 
difficult to keep in mind in any systematic way. There is 
the complexion of the child ; the formation of its bones ; 
the state of its skin and muscle — is it fat, spare, firm, or 
flabby ; its size in proportion to its age ; its general build ; 
the shape of its head ; the state of its fontanelle ; the relative 
proportions of head and face ; the condition of corneae and 
pupils ; the lines upon the face ; the state of the no*strils ; 
the gums, the teeth, the tongue ; the ears ; the shape of the 
chest and its movement ; the abdomen and its movement 
the character of the cry and the state of the nervous system. 
All these facts and many more, indicating as they do points 



15 DISEASES OF CHILDREN. 

negative and positive which are absolutely essential to the 
formation of a diagnosis, and for forecasting the issue of the 
case, and for treatment, must yet, being but preliminaries, 
often be taken in hurriedly, almost at a glance. To allow 
of this being done in any sense completely, it is well to take 
each step in a regular method. Start, however, where you 
like, adopt your own plan, but always proceed as much as 
possible upon this plan : and while rapidity of execution 
comes with practice, abundant compensation will be obtained 
for any trouble that may be involved, in the frequency with 
which, by so doing, conclusions will be arrived at, and 
results obtained, which had not previously been expected, 
and would in all probability have been missed by less 
methodical observation. 

It is impossible, in a short manual, to go much into detail 
in a preliminary chapter,* but one or two points may be 
selected to illustrate the importance of what has been said. 
For instance, the cry of a child may help to distinguish the 
ailment under which it is laboring. There is the noisy, 
passionate cry of hunger ; the wail of abdominal disease ; 
the whine of exhaustion ; the short, sharp shriek of cerebral 
disease ; the hoarse, whispering cry of laryngitis. 

Much may be learned by a glance at the shape of the head. 
The hydrocephalic head is one which bulges in all direc- 
tions. The forehead projects, the temporal fossae become 
convex ; the fontanelle and vertex more vaulted ; even the 
occiput becomes more rounded, and, in this general tendency 
toward the assumption of a globular form in place of an 
ovoid, the inter-ocular space is widened outward, and the 
eyes are rendered too divergent. The rickety head is 
usually an elongated one, and often laterally compressed, 

* For a detailed plan of examination, see " Diseases of the Digestive Organs 
in Infancy and Childhood." — Starr. 



INTRODUCTION. IQ 

and although the forehead may be overhanging, it wants 
the width and general rounding seen in hydrocephalus. 
In other cases it is square, being flattened anteriorly, poste- 
riorly, superiorly, and laterally. The frontal eminences are 
prominent, the sutures are depressed, and the fontanelles 
are late in closing. There is also apparent enlargement, 
due to comparative smallness of the face from arrested de- 
velopment of the facial bones, though actually the cranium 
measured about the same as at the corresponding age in 
health. The head of the syphilitic child is sometimes of 
irregular shape, almost lobulated in appearance, and betrays 
its component bones by the position of the enlargements. 
The disease is one of osteophytic growth, which forms upon 
the bones round the anterior fontanelle, and spreads thence 
over their surfaces. The fontanelle may thus appear to lie 
in a hollow, the frontal bone being unusually prominent, 
and the inter-frontal suture converted into a vertical ridge, 
from the exuberant bone formation along it ; while the 
parietal bones become bossed irregularly. This skull has 
been called the natiform skull, from the appearances pro- 
duced by the bony elevations. It is still an open question 
whether the osteophytic growth is due to syphilis or to 
rickets. The scaphoid skull is a narrow skull, in which 
the frontal region is boat-like, and slopes away from the 
median line, betokening the small brain of an imbecile 
or idiot. 

The fontanelle, by bulging, may indicate excess of blood 
or cerebro-spinal fluid within the cranium ; by its size it 
may indicate defective ossification, and so rickets ; but of 
more importance, because of almost invariable significance, 
is the depressed fontanelle of starvation and exhaustion : it 
indicates the immediate necessity of food or stimulants. 

As to the face, various shades of pallor are most sug- 
gestive — a dirty white stands for congenital syphilis ; a 



20 DISEASES OF CHILDREN. 

sallow white for splenic disease ; a pallor with a sub-tint of 
blue for tuberculosis ; a livid, leaden, or earthy tint for col- 
lapse from abdominal disease. 

There are certain markings upon the face, Jadelot's lines, 
as they are called, from the French physician, who has 
described them very fully. These lines are: 1st, oculo-zygo- 
matic, indicating disease of the brain. This begins at the 
inner angle of the eye, and extends outward beneath the 
lower lid, to disappear a little below the projection of the 
malar bone; 2d. The nasal, pointing to gastro-intestinal 
disorders, or affections of the abdominal viscera. This rises 
at the upper part of the ala of the nose, and passes down- 
ward, to form a semicircle around the corner of the mouth ; 
3d. The labial, denoting disease of the lungs and air-passages. 
Beginning at the angle of the mouth, this line runs outward 
and downward, to be lost at the lower part of the face. 

Then there are the various complexions which are sup- 
posed by many to indicate particular diatheses or tendencies 
to disease — the pretty, thin-skinned children of tubercular 
proclivities; the sallow, muddy appearance of children 
prone to glandular abscesses ; the dark-haired, pallid, but, 
on the whole, well-looking children of nervous habit, and 
so on. Of these, though they have in former times occu- 
pied much of the attention of writers of books, it is neces- 
sary to say but little, because there is now considerable 
want of unanimity upon the subject, and because their im- 
portance is hardly measurable by facts, but depends upon 
observations, the accuracy and worth of which the student 
must test for himself. There is the sunken eye, the dark- 
colored and depressed areola around it, indicative of col- 
lapse ; the dilating alae nasi of acute lung disease ; the 
lividity of lips of chronic lung disease; the puffy, congested 
eyelids, and ecchymosed face of whooping-cough. 

For the chest, we have the immobility of pleurisy ; the 



INTRODUCTION. 2 1 

unnatural precordial bulging of a large heart; the sinking 
in of the lower ribs of atelectasis. 

Of the abdomen, it may be said that enlargement is not 
necessarily due to disease. Children will constantly be 
brought to you for "consumption of the bowels," because 
they have diarrhoea and a large abdomen. In the great 
majority of cases, the enlargement is due to flatulent dis- 
tention from defective feeding ; sometimes to displacement 
of the liver and spleen by distortion of the thorax in 
rickety children. In many such there will be but few cases 
of organic disease, and of mesenteric disease, it may be 
said that it is seldom associated with sufficient abdominal 
enlargement to attract the attention of the child's mother. 
Increase in size of the abdomen, when the result of disease, 
may be due to a large liver or spleen, sometimes to ascites, 
sometimes to tumors connected with the kidney. 

On coming to the more direct examination of the child, 
it is even more necessary to follow a definite plan. It 
matters not how one proceeds, so long as this be done. 
Supposing, as is probable, that some idea of the nature of 
the case has been gleaned from the preliminary survey, a 
good method is to start with the organ which we suspect 
to be involved. If there be any reason for suspecting 
disease of the nervous system, it is as well at once to ex- 
amine the eyes with the ophthalmoscope, lest any subse- 
quent action on our part may frighten the child, and render 
the fundus oculi inaccessible. It is impossible to make any 
satisfactory use of the ophthalmoscope if the child is, or 
has been recently, crying. This done, and the state of the 
pupil and movement of the eyeball ascertained, the sight 
and hearing can be tested by a watch, and the precision of 
the various muscular movements of the extremities, by 
giving the child something to hold or pick up, and by 
making it walk, if old enough, or by watching the move- 



22 DISEASES OF CHILDREN. 

ments of the limbs in infants too young to walk, as they lie 
on the mother's lap. The gums can be examined, and the 
progress of dentition ascertained by gently rubbing the sur- 
face of the gums with the finger. The chest and abdomen 
should be examined in all cases. Some advise that the child 
should be stripped for this purpose, and this is a necessary 
measure in some cases, but is not advised as a rule, for 
the reason that the child is to be frightened or put out of 
temper as little as possible. Children, all but the youngest 
infants, resent the process of undressing, and it is usually 
sufficient for the purpose of examination that all the cloth- 
ing be loosened. The greater part of the front and back of 
the chest can be, by this means, exposed, and a thorough 
investigation made. Percussion must be light or it will 
mislead. A light vertical tap with one or two fingers upon 
a finger of the other hand placed flat upon the chest is all 
that is necessary, and special attention is to be paid to the 
intervertebral grooves, as parts which are more frequently 
implicated in children than in adults. In auscultation it is 
very essential to make careful comparison of the two sides ; 
of the bases with the apices ; and to remember that it some- 
times happens that the more abnormal sounds are heard in 
the healthier lung. A student will often describe as bron- 
chial breathing, the exaggerated, puerile respiration of the 
over-acting, but sound lung, and consider as healthy, the 
soft and deficient vesicular murmur of the diseased side, 
and indeed there is abundant excuse for his so doing. 
Again, disease may be ascribed to the apex of the lung 
from the existence of bronchial breathing, whereas the 
primary disease is really at the base. Therefore, the whole 
of the chest must be auscultated : above and below the clav- 
icles ; the supra-spinous fossae behind ; the intervertebral 
grooves and bases ; and we must be on the alert to detect 
even slight differences between the two sides. 



INTRODUCTION. 23 

The examination of the abdomen is chiefly conducted by 
means of palpation — enlargement of the spleen and liver 
are ascertained in this way. So, also, other abdominal tu- 
mors. But there are other points of detail which are well 
worth attention. In the first place it is often worse than 
useless to put a young child on its back and uncover it for 
examination. It will kick and scream, put its muscles into 
a state of rigidity, and nothing can be made out. One must 
often be content with an examination while it is sitting up 
and by placing the hand beneath its clothes. It is equally 
useless to poke the abdominal wall with the tips of two or 
three fingers, as the muscles are provoked to action by this 
means also, and nothing can be felt behind them. Palpa- 
tion can only be properly conducted by placing the warm 
palm perfectly flat and open upon the abdominal wall and 
making pressure at any part that requires examination with 
the flat of one or two fingers. Any abnormal tumors can 
in this way be readily detected, and their edges defined — 
be they hepatic or splenic or what not. Splenic and renal 
tumors are best examined by one hand being placed flat 
beneath the body supporting the hinder wall of the abdo- 
men, while the other, flat and open as before, makes pres- 
sure from above upon the abdominal wall supported by the 
hand behind. 

The pulse, in infancy, ranges from 90 to 130 beats per 
minute ; the least muscular effort or emotion of anger or 
fright being sufficient to increase the frequency of the 
heart's action from the former to the latter figure. As a 
test of physical strength, the pulse, at this age, is far 
less reliable than the condition of the fontanelle. After the 
age of two years, it becomes a more valuable guide. In 
health it rarely counts more than 100 during the waking 
state, and is some 10 or 20 beats slower in sleep, when, too, 
it is often irregular in rhythm. An increase to 130 occurs 



24 DISEASES OF CHILDREN. 

with any trifling fever, and is consequently not a serious 
symptom. Abnormal slowing, on the contrary, is a grave 
feature, a reduction to 40, for example, frequently attending 
tubercular meningitis. 

The respiration varies in frequency with the age. At 
birth, the average is 40 per minute; from two months to 
two years, 35; and from two to twelve years, 18 during 
sleep, 23 while awake. The movements should be dia- 
phragmatic ; if superior-costal, a painful abdominal disease, 
as peritonitis, is indicated; if abdominal, pleuritis or pneu- 
monia. Very rapid breathing attends cardiac disease and 
inflammatory affections of the lungs or pleura ; slow, sighing 
respiration, interrupted by long pauses, tubercular menin- 
gitis. The normal ratio of respiration and pulse is 1 to 3 
or 3.5 Should this be changed to 1 to 2, pneumonia or 
pulmonary collapse may be suspected. 

The temperature of children is often puzzling. It is 
much more unstabLe than in adults, and abnormal heat is 
more liable to escape notice. Temperatures of 102 and 103 
are frequently overlooked in infants, the child being said to 
be simply out of sorts, and fretful. So also in children of two 
or three years old. The temperature of some children is dis- 
turbed much more readily than that of others. Some there 
are who, in the first six or eight years of life, whenever they 
eat anything which is at all indigestible, and often at other 
times with no very definite cause, suffer from an acute febrile 
disturbance, with cough and foul tongue. A mild aperient 
stops the whole thing. Others, again, have sharp fever with a 
slight sore throat. A number of children have a simple con- 
tinued fever of hectic type — viz., normal in the morning and 
up at night — which puzzles us by the absence of other symp- 
toms, and the fear of typhoid fever or tuberculosis haunts 
the doctor. Dr. Goodhart offers the notes of a case which 
emphasizes these remarks and gives the student an idea of 



INTRODUCTION. 25 

some of the difficulties, as regards temperature, which are 
every-day realities in practice. A child of six years was 
taken suddenly ill, his symptoms being slight sore throat, a 
croupy cough, high temperature, and a rapid pulse. His 
cough and sore throat gave ground for anxiety that an 
attack of diphtheria might be impending ; but he persist- 
ently complained of pain in the epigastrium, and this, with 
a short, catchy respiration, suggested the possibility of some 
diaphragmatic trouble. His mother, many years before, 
had had rheumatic fever, and a careful examination of the 
child's heart revealed an undoubted systolic prolongation 
of the first sound about the base, which was compatible 
with the existence of an early pericarditis, but hardly less 
so with the long and thick first sound which is one of the 
accompaniments of sharp fever. The epigastric pain and 
peculiar breathing, with the altered heart-sound, and the 
family history, pointed to the possibility of the onset of 
acute pericarditis and rheumatism, while the sore throat 
and cough would also fit in with this presentation of the 
symptoms. On the other hand, the child was in no distress, 
nor did he appear to be seriously ill. He had a bright eye, 
a flushed cheek, dry, red lips, a pungently hot skin, and a 
frequent, short, dry cough, at least as suggestive of pleu- 
risy or pneumonia ; and, with this idea in mind, there were 
some slight indications in diminished resonance at the left 
apex, and some questionable, because distant, bronchial 
breathing about the root of the lung, that acute pneumonia 
might have set in. Lastly, at any rate in his purview, the 
children of this family were markedly excitable or neurotic. 
Such children, from inexplicable reasons, are liable to sud- 
den sharp febrile attacks, in which cough and rapidity of 
pulse are prominent symptoms, and which closely simulate 
the onset of acute thoracic disease. The problem speedily 
solved itself, for, on the third morning, an aperient and 



26 DISEASES OF CHILDREN. 

some alkaline draught having been given meanwhile, the 
fever had subsided, and the boy was practically well. 

The ejecta of children should all be examined, whether 
they be vomited or passed from the bladder or rectum. 

The sleep of a child should be watched if opportunity 
offer. A child sleeps quite calmly when in health, and for 
a long time at a stretch when the first few months are passed 
over and the necessity of frequent suckling has gone by, 
but it is quickly disturbed in disease. Slight attacks of 
fever, gastro-intestinal derangements, dentition, brain dis- 
ease, etc., all make the sleep uneasy, although not much 
differentiation of disease can be accomplished by observa- 
tions of this kind. 

The manner of deglutition is another feature which 
often conveys an indication of disease. For in any inter- 
ference with the freedom of respiration a child will take a 
few snatches of food and then turn away and splutter, or 
cough, or cry. If children refuse food without any definite 
reason, the mouth and throat should always receive a care- 
ful examination; stomatitis, tonsillitis, and even more serious 
troubles, such as post-pharyngeal abscess, may otherwise 
go unrecognized. 

By persistently following out the spirit of these prelimi- 
nary suggestions in the way that seems best suited to the 
individual examined, it will be but seldom that a very 
refractory child is met with, or that a satisfactory examina- 
tion cannot be made. 

GENERAL REMARKS ON TREATMENT. 
The dosage for children, the one great dread of students, 
is a matter which, if stated with precision in a posologi- 
cal table, is rarely handy for reference, and is hardly 
reliable if it be. Nevertheless, as a guide to the student, 
Cowling's rule is serviceable ; namely, the proportionate 



INTRODUCTION. 27 

dose for any age under adult life is represented by the 
number of the following birthday, divided by twenty- 
four, i. e., for one year -^ = -jL- ; for two years ■£% = \, and 
so on. With one or two exceptions, every one must make 
his own table in his own memory, and must feel his way. 
Herein is one of the advantages of experience, which can 
hardly be gained in any other manner. Opium has been a 
great bugbear in this respect. All powerful drugs must 
naturally be given with caution to children ; but opium is 
perhaps the only one which requires excessive precaution. 
It must be given to infants in infinitesimal proportions, and 
there are some practitioners who evade its use at this time 
of life as much as possible. Still, combined with castor-oil, 
it is a useful drug in bad cases of flatulent colic, and perhaps 
one drop of laudanum to a two-ounce mixture, of which a 
drachm may be taken, is an average dose in the first six 
weeks of life. This quantity may have to be lessened, but 
it will certainly, in many cases, be necessary to increase it, 
and after the first two or three months the extreme suscep- 
tibility to the drug disappears, and half a drop may then 
be given for a dose. At two or three years old, two-grain 
doses of Dover's powder may be given, when requisite, 
without fear. 

Bromide of potassium, a most valuable remedy in many 
of the diseases of children, must be given to infants with 
watchfulness. It sometimes, even in small doses, produces 
severe local inflammation of the skin, and localized patches 
of soft, warty growths. This is, however, of infrequent 
occurrence, and cannot be avoided when, as is sometimes 
the case, the idiosyncrasy is so pronounced that three or 
four grains suffice to produce the eruption ; but, for the 
reason that there is a risk, the drug should not be continued 
for any length of time, except under close supervision. 



28 DISEASES OF CHILDREN. 

Belladonna and arsenic are illustrations of an opposite 
tendency, for children are very tolerant of these drugs, par- 
ticularly of belladonna. A child four or five years old will 
take five to ten drops of tincture of belladonna without any 
inconvenience whatever. And in cases in which it is neces- 
sary to give arsenic to children of six years and upward, a 
dose of five drops of Fowler's solution may be given at the 
outset three times a day, and a considerable increase on this 
be attained if necessary. Such initial doses are, however, 
occasionally productive of the symptoms of mild arsenical 
poisoning, and, therefore, it. is well to begin with one or 
two-drop doses, and increase as necessary. This rule ap- 
plies especially to children belonging to the wealthier 
classes, for these, like their parents, are much more sensi- 
tive to drugs than*hospital patients — an undoubted physio- 
logical fact of wide bearing. 

Alcohol is a drug frequently indicated and of great 
value, though it is by no means to be administered indis- 
criminately. It is most useful in broncho-pneumonia; 
severe febrile conditions ; in the prostration following 
measles, diphtheria and whooping-cough, and in the col- 
lapse often accompanying severe thoracic or abdominal 
disease. 

Dr. Lewis Marshall advises — and the plan is safe — a 
resort to aromatic spirits of ammonia before brandy or 
whiskey, in cases demanding a stimulant ; the aromatic 
spirit is to be given in doses of two to five drops, frequently 
repeated and with food. Some parents object to giving 
their children any of the ordinary alcoholic liquids, but this 
difficulty may be readily overcome by ordering compound 
tincture of cardamon or a prescription containing alcohol 
itself. 

Finally, children do not often require very energetic 



INTRODUCTION. 2Q 

treatment with drugs, and probably he will be the best 
practitioner who lets Nature make for cure without heroic 
measures. Proper feeding and hygiene rank first in all 
treatment in early life. 

It is necessary to add that all drugs should be made 
as palatable as possible. Castor-oil and quinine may be 
very good remedies, but, except to babies, they are very 
disgusting, and there are now at hand numberless substi- 
tutes, and methods of disguising nasty remedies, which 
should be studied. Some may be put into lozenges, some 
into syrups, some mixed up into a palatable emulsion, and 
so on. 

Baths are important therapeutic agents ; indeed, it would 
be difficult to enumerate the variety of diseases in which a 
bath is useful. As a general rule when a state of pyrexia 
is recognized, the child is likely to be smothered to keep it 
warm. For the same reason, the linen which is not actually 
soiled by the excreta, is not changed for fear of chill. But 
children of all ages perspire freely, and in the course of a 
few hours will get exceedingly uncomfortable under these 
circumstances, fretting and becoming restless, while the 
mother wonders why sleep does not come. Put the child 
into a warm bath for a few minutes, and with fresh linen 
and a comfortable cot it will probably soon be at rest. 
Then, too, in most states of fever, sponging is of value — 
warm, or tepid, or cold, according to the necessities of the 
case — and a bath, even a warm bath, will reduce the tem- 
perature if it be very high. Tepid or cold baths may be 
administered to children in high fever, if requisite, but if 
cold the bath must be of short duration. A fall of tem- 
perature is set going by the immediate shock, not neces- 
sarily by prolonged immersion, and the latter is liable to 
induce a state of collapse and exhaustion, such as is not 
often seen in adults. 
3 



30 DISEASES OF CHILDREN. 

The following table gives an idea of the different tem- 
peratures of the water used in the various baths : * — 

1. Cold, temperature, 50 to 65 F. 

2. Cool, " 65 to 75 

3. Temperate, " 75 to 85 

4. Tepid, « 85 to 92° 

5. Warm, " 92 to 98 

6. Hot, " 98 to 112 

The tender skin of a child should always be a matter of 
attention. Poultices and hot bottles easily scald, and ban- 
dages are very liable to cut or excoriate if not carefully 
applied, and frequently readjusted. Poultices are in frequent 
use for cases of thoracic and abdominal disease. They 
should never be so hot as to be in any degree painful. 
Discard them as much as possible, however, for they soon 
become cold, hard, and uncomfortable, and are often heavy. 
A warm fomentation, by means of spongio-piline, well cov- 
ered in by cotton wool, is in every way preferable, at any 
rate, for diseases of the thorax. A layer of cotton, covered 
with oiled silk, by condensing the insensible perspiration, 
and becoming moist, also acts in the same manner, and is 
preferable to a poultice, in both thoracic and abdominal 
diseases, since it does not require changing, and is always 
warm. 

DIET OF CHILDREN IN HEALTH. 
The student often starts in practice with such limited 
notions on the subject of diet, that many a mother knows 
more of what is actually required than he does. True, 
indeed, the fundamental rule upon which all practice is 
founded, that the mother's milk, and that only, should 

* For the methods of administering these baths, consult " Hygiene of the 
Nursery." — Starr. 



INTRODUCTION. 3 I 

form the infant's food for the first few months of life, is a 
choice stock in trade, but we. soon find out how very 
limited, and often at fault is this statement of the matter. 
Many mothers cannot, some mothers will not, nurse their 
infants at all, and many more are so situated through the 
calls of society, or of business, that this, the chief of 
maternal duties, can only be fulfilled in part. Thus it 
early becomes a question for all of us — What is to be 
done under each or any of the circumstances which this 
enforced neglect entails ? 

It will be well to attend to the following suggestions : — 

The infant should be fed from its mother's breast, if not 
for the full period of lactation, at least so long as possible, 
and if not entirely, then partially — that is to say, the breast 
should supply at least one or two meals daily. 

If the mother be able to suckle it entirely, no other food 
is to be given to the infant. It is to be put to the breast 
every two hours for the first five or six weeks, between six 
A. m. and ten p. m., and afterward the interval between the 
meals is to be lengthened gradually, till a three-hour interval 
is reached. Of course, should the mother be affected with 
either syphilis or advanced phthisis, this rule does not hold. 
It is said that a healthy child will sleep all through the 
night hours, but in the first five or six weeks of life, it will 
require food several times during the night. Even when 
infants are some months old one meal in the middle of the 
night may be necessary, and to this there is but little 
objection. The digestion of a healthy infant is rapid, and, 
while it should not be allowed to have food too often, any 
lengthened fast is equally to be avoided. 

The interval between meals is to be strictly enforced for 
all infants that are healthy. Children are creatures of habit, 
and soon learn their proper meal-times. They will often, 
indeed, begin to cry punctually at the time. But they also 



32 DISEASES OF CHILDREN. 

are easily educated in faulty habits. It is the custom of 
many mothers to pacify crying at all times with the breast 
or the bottle — and a more pernicious practice it is impossible 
to conceive. The more the crying the more the feeding, and 
the more infants are fed the more they cry, and what between 
crying and sucking the day and night are spent in misery. 
These are the cases which form the great majority of the 
thin, pining, pitiable mites who are brought to a hospital 
" for consumption of the bowels," but with bad feeding only 
to blame. And what wonder ; if grown-up persons were to 
be always eating, who among us would not be dyspeptic, 
and who would not be quite as miserable, if less demonstra- 
tive than the infant ! Now let it be remembered that there 
are many children who in the first week or two of life, when 
the stomach is, as it were, unfolding to its duties, cry a good 
deal. They are a source of great discomfort and pain in a 
household — sucking at something will almost certainly quiet 
them, and other methods of treatment, food, doctoring and 
so forth, often fail. It is very important in such cases to 
impress upon the mother and nurse that if they quiet a child 
by this means, they are but sowing the wind to reap an in- 
evitable whirlwind. • If they bear with it for a short time the 
child soon becomes accustomed to the habits enforced ; it 
must sleep after a while, and the first lesson of its life is 
learned. Whenever there is much crying, however, attention 
should be directed to the quality of the milk. It may 
be poor in quality or deficient in quantity, and the child 
cries because its stomach is full of flatus. Sometimes, 
again, it is over-plentiful, and the child taking it too 
greedily is troubled in consequence with colic. This 
latter trouble can be prevented, should the milk flow too 
freely, by slight pressure with a finger above and below 
the nipple. 

If it be necessary to make any addition to the breast 



INTRODUCTION., 33 

milk, good cows' milk* may be tried first, and it is to be 
diluted with an equal part of water, or equal parts of milk 
and lime-water slightly sweetened with sugar of milk or 
lump sugar, six tablespoonfuls to be given at a meal. The 
breast may be given night and morning, and the milk and 
lime-water in the meantime, or the two may be made to 
alternate. The milk may be boiled in hot weather, if it 
disagree^ and to one or two of the daily meals, sometimes 
to all of them, a good teaspoonful of cream may be added. 
The mixture of milk and lime-water is not by any means 
always suitable. In some cases, where the milk is still too 
much for the child, and is most of it vomited in large curds, 
it may be further diluted. In others, where it appears to 
lead to flatulence and abdominal pain, a mixture with thin 
barley-water will be found to agree better. Barley-water 
has also the advantage of acting as a gentle laxative, a 
very valuable property, inasmuch as many children fed 
upon cows' milk and water, or cows' milk and lime-water, 
are much troubled with constipation, the motions being very 
large, lumpy and hard. Barley-water acts most beneficially 
in many such cases, but its use is to be watched, as infants 
are very sensitive to the administration of starch in any 
form, and the author has repeatedly known an eczematous 
eruption to appear upon the buttocks after only one or two 
meals of milk treated in this way. In very young infants 
the mixture of milk and water, or milk and lime-water, may 
produce vomiting or abdominal pain. In such cases the 
milk must be diluted till it forms only a third part of the 
whole, equal parts of milk, water, and lime-water being given, 
sweetened as before with milk sugar. But there are many 

* Cows' milk should be faintly acid or neutral; have a sp. gr. of 1029, and 
should contain an amount of cream which is variously stated by different writers 
to be from 5 to 10, or even 14 per cent. 

f Sterilization is better, see page 36. 



34 DISEASES OF CHILDREN. 

cases where this fails to secure the child's health and com- 
fort. It is griped with pain after each meal, and.it remains 
thin, while the motions are still pale and lumpy, often con- 
taining undigested curd. It is probable that, under these 
circumstances, the curd of the cows' milk, which is larger 
and firmer than that of human milk, is the element at 
fault, and barley-water will often remedy this. By mixing 
it with the milk the casein curdles in a state of more minute 
subdivision, and more closely resembles the thin, small 
flocculent curd of human milk. Meigs and Pepper advise 
a little arrowroot in addition. Thin gelatin jelly, a teaspoon- 
ful to half a pint of milk and water, may be mixed with the 
milk instead of the barley-water, for the same purpose. 
Several " Infant's Foods" maybe used for the same purpose 
also. These are, for the most part, combinations of farina- 
ceous food in which the starch has been converted into 
dextrine and grape sugar by the process of preparation. In 
this state they are easy of digestion, and may, therefore, 
with due care, be used to thicken the milk. Starch, which 
has undergone no such changes, is unsuitable, because in the 
first three months of life the salivary and pancreatic juices 
are wanting, and consequently there are no facilities for its 
digestion. The various foods prepared in accordance with 
Liebig's process are useful in certain cases. Sometimes one 
will suit, sometimes another. The proper one for a partic- 
ular case must always be somewhat a matter of experiment. 
A teaspoonful is added to each meal. 

In regard to the subject of " infant's foods " as a class, we 
prefer to use such as can be added to sound cows' milk, 
and not such as are to be used as substitutes. As every one 
knows, all sorts of concoctions are abroad which are sup- 
posed to outdo nature, its appropriateness of composition 
and directness of aim. But competition is a hard taskmas- 
ter and nature an exacting customer. It is impossible to 



INTRODUCTION. 35 

feel confident that in any given case the necessary adapta- 
tion of means to ends will be accomplished. Therefore, as 
a general rule, let it be understood that in some proportion 
good, fresh cows' milk should form part of every food. 

Condensed milk of some good brand is often useful at 
this period of life, and some infants apparently thrive well 
upon it. It possesses some good qualities, chief of which 
is its freedom from any tendency to turn sour or curdle 
after ingestion. Care must be taken not to give too much 
of it. A small teaspoonful to a teacupful of water is quite 
sufficient for a meal, and after two or three months it should, 
in most cases, be replaced by cows' milk, or combined with 
some " infant's food." Condensed milk possesses the advan- 
tages of making very fat, hearty-looking babies. The dis- 
advantages are, that it gives little strength to resist disease, 
and infants fed upon it cut their teeth late, and otherwise 
show the symptoms of a moderate rachitic tendency. To 
make condensed milk a good general food, i. c, sufficient for 
the demands of nutrition, it must be enforced by the addi- 
tion of cream and one of the better "infant's foods." For 
example, a nutritious mixture may be made as follows: — 

Condensed milk (Eagle Brand), .... two teaspoonfuls. 

Water, twelve tahlespoonfuls. 

Cream, two teaspoonfuls. 

Mellin's food, one teaspoonful. 

All food-preparations containing condensed milk, how- 
ever, should be regarded as make-shifts ; in artificial feeding 
the object always being to get the child as soon as possible 
upon a good cows' milk mixture.* 

There is one form of condensed milk which does not 
possess the disadvantages of the canned article ; this is 

* For particulars upon this point, see " Diseases of Digestive Organs in In- 
fancy and Childhood." — Starr. 



36 DISEASES OF CHILDREN. 

called " fresh condensed milk." In preparing this the cows' 
milk — which is selected with the greatest care as to quality 
and soundness — is subjected for an hour or more to a tem- 
perature of 210 F., under pressure. This procedure, be- 
sides practically sterilizing the milk, so alters its casein that 
when subjected to a curdling agent it coagulates in light 
flakes resembling those of human milk. Being sterilized, 
too, the addition of cane sugar for preservation is not re- 
quired ; in an ice box or refrigerator it keeps perfectly fresh 
for six or more days. 

Fresh condensed milk should of course be diluted with 
pure water at the time of administration ; one part to six- 
teen is the proper proportion for an infant a week or two 
old and the strength is gradually increased as age advances, 
one part to eight being the proper proportion at the age of 
six months. It has been proved that infants fed upon fresh 
condensed milk do not lose fat any more rapidly during 
illness than those who have been fed upon the breast or 
fresh cows' milk food. 

Great and deserving stress has recently been placed 
upon a method of preparing, or rather preserving, cows' 
milk, known as " Sterilization." As milk exists in the 
healthy cow's udder it is aseptic, i. e. y free from any poison- 
ous or dangerous ingredient, but during milking, and sub- 
sequent handling and transportation, particles of manure 
or various forms of dirt get into it and are apt to set up 
fermentation or other injurious change. To deprive these 
accidentally introduced organic impurities of their activity, 
or, in other words, to sterilize, it is necessary to subject the 
fluid to high heat under pressure. 

Several admirable implements have been devised for con- 
ducting the process ; one of the most simple, made after a 
design of the American collaborator, is shown in the accom- 
panying figure. 



INTRODUCTION. 



37 



This apparatus is made of tin, and consists of an oblong 
case provided with a well fitting cover, and having a mov- 
able perforated false bottom (D), which stands a short dis- 
tance above the true one and has attached a framework 
capable of holding ten, six-ounce, graduated nursing- 
bottles. On the outside of the case is a row of supports 
(B) for holding inverted bottles while drying, and at the 
proper distance below these a gradually inclining gutter (C) 
for carrying off the drip. A movable water bath (A) is 

Fig. i. 




hung to the side ; in this each bottle of food may be heated 
at the time of administration. 

The bottles are made of flint glass, so that the slightest 
foulness can be detected at a glance ; the graduated mark- 
ings being especially convenient for measurement, and ren- 
dering the use of a separate measuring-glass unnecessary, 
a matter of no little moment, as every instrument that 
comes in contact with the milk in sterilization must be 
kept chemically clean. Ten bottles are used, so that the 
4 



38 DISEASES OF CHILDREN. 

whole supply of milk intended for a day's consumption 
can be prepared at once. Each bottle is provided with a 
perforated rubber cork, which in turn is closed by a well- 
fitting glass stopper. 

Sterilization should be performed in the morning as soon 
as possible after the milk has been served. The process is 
as follows : First, see that the ten bottles are perfectly clean 
and dry; pour into each six fluidounces of milk; insert 
the perforated rubber corks, without the glass stoppers, 
however ; remove the false bottom and place the bottles in 
the frame ; pour into the case enough water to fill it to the 
height of about two inches ; replace the false bottom car- 
rying the bottles; adjust lid, and put the whole on the 
kitchen range. Allow the water to boil, and, by occasion- 
ally removing the lid, ascertain that the expansion that 
immediately precedes boiling has taken place in the milk ; 
then press the glass stoppers into the perforated corks, and 
thus hermetically close each bottle. After this, keep the 
apparatus on the fire and the water boiling for twenty min- 
utes. Finally, remove the false bottom with the bottles ; 
pour out the water, replace and carry the whole, covered 
with the lid, to the nursery. 

When the hour of feeding arrives, put one of the bottles 
into the attached water bath and heat it to the proper point 
for administration. The milk may, of course, be diluted 
with filtered water previously boiled, or receive the addi- 
tions ordinarily made to adapt it to children of different 
ages. The tip used (a tube should never be employed) 
should be thoroughly cleansed and immersed for a few 
moments in boiling water before it is attached to the bottle. 

So soon as the bottle is emptied — and if the whole of its 
contents be not taken, the remainder must be thrown away 
— it is carefully washed with a solution of bicarbonate or 
salicylate of sodium and placed in the rack (B) to drain. 



INTRODUCTION. 



39 



Milk sterilized by the above process will remain sound 
for several days, and when the heating is continued for 
thirty minutes it has been found to keep perfectly sound 
for eighteen days. 

Sterilized milk is especially useful in traveling, when 
fresh milk cannot be obtained ; for use in cities during the 
heat of summer, when milk is most apt to undergo inju- 
rious changes ; for the feeding of delicate children, or for 
those suffering from disease of the stomach or intestinal 
canal. 

As regards the quantity of food, it has been estimated 
that the mother supplies to her baby from 12.5 to 16 fluid- 
ounces of milk in the twenty-four hours during the first 
five weeks of life, and that this quantity gradually increases 
until in the later months of lactation about three pints is 
reached. Some such quantity, therefore, distributed over 
regular intervals, should be the daily allowance to a child 
from birth onward. But infants vary much in respect of 
the quantity which they will digest. Some are habitually 
small feeders. Therefore, provided that the child grows, 
that its flesh is firm, and it is happy, there should be no 
absolute insistance upon a fixed minimum. 

As an average, the following table may be useful to the 
student : — 



Age. 



First week, 

Second and third weeks, 

Fourth week, 

Fifth week, 

Sixth week, 

Seventh and eighth \ 

weeks J 

Third, fourth and fifth ) 

months, J 

Sixth month and onward, 



Intervals 
of Feeding. 



Number of 

Meals 
in 24 Hours. 



2 hours. 
2 " 

2 " 

2V2 " 

2/ 2 " 

*y 2 " 
3 

7,10,1, 5,9, i(?); 



Average Average 
Quantity Quantity in 
per Meal, the 24 Hours. 



6 or 7 



S 7.io,i,4 ' 
l7,i°,i(?) 
5 or 6 



-i. l / 2 oz. 

2-2*^ oz. 

2^-3 oz. 

4 oz. 

4V2 oz. 

50Z. 

6 or 7 oz. 

7 or 8 oz. 



16-1S oz. 
20-25 oz - 
25-30 oz. 

32 oz. 

36 oz. 

40 oz. 

42 oz. 
42 oz. 



40 DISEASES OF CHILDREN. 

In some cases, notwithstanding all the care and skill that 
are lavished upon them, cows' milk cannot be digested. Till 
lately, goats' milk or asses' milk has been resorted to, either 
of which resembles the human milk more nearly in its 
poorness of curd. They may be given either undiluted or 
diluted — as in the case of cows' milk — with water or 
lime-water, or even diluted with barley-water. Whey, with 
a tablespoonful of cream added to each meal, is another very 
useful food when milk disagrees ; and, of late, two other 
valuable additions have been made to an infant's dietary in 
peptonized milk and artificial human milk. 

One other food still requires mention, that which goes by 
the name of " strippings." All infants digest cream with 
facility ; the curd, on the other hand, is with all an obstacle. 
Strippings, obtained by remilking the cow after its usual 
supply is withdrawn, is rich in cream and poor in curd, and 
consequently has much to recommend it as an infant's food. 
Dr. Eustace Smith commends it highly, diluted with water or 
barley-water, in cases where other combinations are assimi- 
lated with difficulty. 

There is one other way of preparing cows' milk which 
renders it very acceptable to a delicate stomach, i. e., arti- 
ficial digestion. There are two forms of predigested milk 
much employed in this country, namely, the "peptonized 
milk" and "humanized milk." 

To prepare peptonized milk, put into a clean quart 
bottle five grains of pancreatin,* fifteen grains of bicar- 
bonate of sodium, and four fluidounces of cool, filtered 
water ; shake thoroughly together, and add a pint of fresh, 
cool milk. Place the bottle in water, not so hot but that 
the whole hand can be held in it for a minute without dis- 



* That manufactured under the name of extractum pancreatis, by Fairchild, 
Brother & Foster, of New York. 



INTRODUCTION. 41 

comfort, and keep the bottle there for exactly thirty minutes. 
At the end of that time, put the bottle on ice, to check 
further digestion and keep the milk from spoiling. The 
fluid obtained, while somewhat less white in color than 
milk, does not differ from it in taste ; if, however, an acid 
be added, the casein, instead of being coagulated into large, 
firm curds, takes the form of minute, soft flakes, or readily 
broken-down feathery masses of "small size. When the 
process is carried just to the point described, the casein is 
only partly converted into peptone ; but every succeeding 
moment of continued warmth lessens the amount of casein 
until peptonization is complete. Then the liquid is grayish- 
yellow in color, has a distinctly bitter taste, and shows no 
coagulation whatever on the addition of an acid. This 
artificial digestion, therefore, may be carried just as far as 
circumstances indicate, although it is ordinarily best to stop 
it short of complete conversion, as children object to the 
markedly bitter taste, and often, on account of it, absolutely 
refuse the food. Partial peptonization, too, is usually suffi- 
cient to adapt the milk to ready assimilation. To seize the 
proper moment for arresting the process, the person con- 
ducting it must be told to taste the milk from time to time, 
and as soon as the least bitternes's is appreciable to remove 
the bottle from the hot water and place it upon ice for 
cooling and use. Such milk may be sweetened with sugar 
of milk, and given pure or diluted with water. For an 
infant of six weeks, each meal may consist of — 

Peptonized milk, 6 tablespoonfuls. 

Milk sugar, y z teaspoonful. 

Water, = . . . 2 tablespoonfuls. 

To this cream may be added when desirable, and, by 
diminishing the quantity of water and increasing that of 
milk, the strength of the food may be made greater at any 
time. 



42 DISEASES OF CHILDREN. 

Although every precaution be taken, the last of a quan- 
tity of predigested food is very apt to grow bitter ; and if 
the attendants will take the trouble, it is much better to 
peptonize every meal separately. This is readily done by 
obtaining a number of powders of pancreatin and bicar- 
bonate of sodium, so proportioned that each packet shall 
contain the proper amount for one bottle of food. 

Humanized. milk is prepared with an article known as 
" Peptonized Milk Powder," furnished by the chemists 
already referred to. This powder contains a digestive 
ferment (pancreatin); an alkali, bicarbonate of sodium, and 
a due proportion of milk sugar. The mode of employment 
is as follows : — 

Take of — 

Milk, 4 tablespoonfuls. 

Water, 4 tablespoonfuls. 

Cream, I tablespoonful. 



Peptogenic milk powder, I 



measure 



This mixture is to be heated over a brisk flame to a point 
that can be comfortably sipped by the preparer (about 1 1 5 ° 
F.) and kept at this heat for six minutes. When properly 
prepared, the resultant, so-called " humanized milk " pre- 
sents the albuminoids in a minutely coagulable and digesti- 
ble form, has an alkaline reaction, contains the proper 
proportion of salts, milk sugar and fat, and has the appear- 
ance of human milk. 

Leeds gives the following analysis of this prepared 
milk : — 

Water, 86.2 per cent. 

Fat, 4-5 

Milk sugar, 7. " 

Albuminoids, 2. " 

Ash (salts), 0.3 " 



Measure provided with each can of powder. 



INTRODUCTION. 43 

This corresponds very closely with his average analysis of 
human milk. 

In using this powder, too, one can readily return to 
a plain milk diet by gradually shortening the time of 
heating ; in other words, by slowly diminishing prediges- 
tion. 

It will be seen that the active ingredient in making 
both of these forms of food is the same. Certain additions, 
however, have been made in the peptogenic milk powder 
which render its food product abetter substitute for human 
milk.* 

As a last resource a wet-nurse must be obtained. In 
selecting her, attention should, of course, be paid to her 
appearance and state of health. Inquiries should be made 
for any previous symptoms indicative of syphilis ; the skin 
and throat should be examined for scars, etc. It may per- 
haps be advisable that, where there is a choice, a nurse 
should be chosen of similar complexion to the infant. The 
state of the breasts must be examined, their distention, the 
state of the nipples, and the quantity and quality of the 
milk. It is well, too, to be prepared with a second nurse, 
as the first selection may after all fail in some way or 
another. Infants, as well as their parents, have unaccount- 
able likes and dislikes. 

In selecting a wet-nurse one who has previously suckled 
an infant, but who is yet young and robust, and whose child 
is of nearly the same age as the one to be nursed, should 
be chosen. The slightest tendency to phthisis is cause for 
rejection. A woman of violent or quick temper should not 
be engaged. The character of the breasts and milk are also 
to be considered. Blondes make better nurses than bru- 



* For full directions for artificial digestion of foods, see " Hygiene of the 
Nursery. ' ' — Starr. 



44 DISEASES OF CHILDREN. 

nettes. The nipples then will be rose-colored, and should be 
prominent The breast need not be large, but should show 
large veins marbling the skin. The milk of a healthy woman 
is of a bluish-white or pure white color. It should be ex- 
amined in reference, 1st, to its reaction; 2d, its specific gravity; 
3d, to the amount of cream. The reaction should be slightly 
alkaline; the specific gravity 1030 to 1032. The cream 
should be in the proportion of a little more than 4 per cent. 

While upon this subject, however, it may be as well to 
say that in our opinion — so long as we have to do with chil- 
dren who have not persistently wasted for some time — care- 
ful artificial feeding will seldom fail. This is the more to be 
insisted upon both as a hope, and as a motive for persever- 
ance, since wet-nurses are in many families — perhaps in 
most — an impossibility. They are difficult to get at the 
proper time ; they are a considerable expense ; they intro- 
duce a sudden and dominant influence into a household, for 
which it finds itself unprepared — not to mention the moral 
considerations, which cannot be altogether ignored — so that 
it generally comes to be a question of what artificial food is 
the best. 

Suppose now that by the aid of one or more of these 
suggestions the infant has safely reached the age of eight 
months, the time arrives for some addition to its diet. In 
the case of a child fed entirely upon the breast milk, two 
meals a day of cows' milk should now be introduced, a tea- 
cupful at each meal. Should any discomfort be experienced 
after them it may generally be remedied by boiling the 
milk, by the addition of a third or fourth part of lime-water, 
or one of the many infant's foods is to be added, first to 
one, and then to two meals daily.* Nestle's, Liebig's or 



* For further suggestions on this point, see " Diseases of Digestive Organs in 
Infancy and Childhood." — Starr. 



INTRODUCTION. 45 

Mellin's food agree well with many children — a teaspoonful 
is to be well mixed with a teacupful of hot milk. Nestle's 
food should be boiled with the milk. The food may be 
varied by, or alternate with, Chapman's entire wheaten 
flour. This form is more suitable than white bakers' flour, 
because it contains the pollard or outer part of the grain of 
wheat, and this is rich in nitrogenous matter, fat and salts, 
and also in the cerealine, which exercises a diastatic action 
upon the starch, turning it into sugar. 

The finest dressed white flour contains less nitrogen and 
more starch, and is therefore less wholesome, for reasons 
previously stated. The entire flour needs prolonged boiling 
for its preparation in order to break up its starch and con- 
vert it into dextrine or grape sugar. This may be done by 
putting it into a basin, tying it over with a cloth, and then 
immersing the whole in a saucepan of boiling water for 
some hours ; or, by tying it up tightly in a pudding-cloth 
and boiling. Eustace Smith orders a pound to be heated 
thus for ten hours, and then removed ; the outer soft part 
to be cut away, and the inner hard part grated and used as 
meal — a teaspoonful at a time, well mixed with cold milk, to 
which a quarter of a pint of hot milk is added before serving. 

Should the child have already taken to artificial feeding, 
according to the rules laid down, all that will be necessary 
at seven or eight months, will be to increase the quantity of 
milk and food which has already by experience been found 
to suit the particular case. 

After nine months old,* further variety may be intro- 
duced. A cup of beef-tea ; or, mutton-, chicken-, or veal- 
broth ; or the yelk of an egg should be given occasionally. 
All these things are, however, only accessories to the main 



*For detailed diet tables for different ages, see "Diseases of Digestive 
Organs in Infancy and Childhood." — Starr. 



46 DISEASES OF CHILDREN. 

article of diet — i. e., good milk, of which a healthy child 
should consume a pint and a half or two pints daily. At 
this time of life it should have five meals during the day, 
thus. At eight a.m., a teacupful of warm milk thickened 
with a teaspoonful of Nestle's or Mellin's food, or entire 
flour. At eleven a.m., a breakfast-cupful of warm milk, or 
the yelk of an egg well beaten up in a teacupful of milk, 
or a teacupful of veal-broth or beef-tea. At two p.m., a 
breakfast-cupful of warm milk. At six p.m., a teacupful of 
milk with a teaspoonful of Nestle's or Mellin's food or 
baked flour. At eleven p.m., a teacupful of warm milk. If 
the child sleeps through the night, well and good. But 
there is no objection to a night meal of a teacupful of milk 
about three a.m., if it be wakeful. 

At a year old the breakfast may consist of a teacupful of 
milk, a slice of bread and butter, and the yelk of an egg 
lightly boiled. At eleven, a teacupful of milk and a rusk. 
At two, a teacupful of broth or beef-tea with a little bread, 
and at six, a breakfast-cupful of milk, with bread and but- 
ter. The meals may be varied by substituting a teaspoonful 
of oatmeal, well boiled, in a breakfast-cupful of milk ; or 
bread and milk for the egg at breakfast ; and a tablespoonful 
of custard pudding may be added to the dinner. The child 
may next have a little well-mashed potato, or well-cooked 
cauliflower or broccoli added to its dinner — a tablespoonful 
well soaked in gravy. 

After two years, or when the double teeth have appeared, 
it may begin with meat, and the meal-hours may be some- 
what altered. At eight a.m. breakfast, a breakfast-cupful of 
bread and milk or milk with thin bread and butter and the 
yelk of an egg lightly boiled. Thin porridge may be sub- 
stituted on some days. A drink of milk with a rusk may 
be given if necessary during the morning. At half-past 
one dinner, a tablespoonful of pounded mutton, with some 



INTRODUCTION. 47 

mashed potato and gravy, or a cup of beef-tea in which 
some vegetable has been stewed, and a little toast and 
water to drink. At five, a breakfast-cupful of milk, thin 
bread and butter, and stale sponge-cake. No other meal 
will be necessary, but a little milk may be at hand in case 
of need. 

After two years meat may be given daily, and fine minc- 
ing may be substituted for pounding. Light farinaceous 
pudding may also constitute part of the daily mid-day 
meal ; the other meals remaining as before. 

One is often asked, in the case of older children, to draw 
out a diet table, but this is usually unnecessary. All chil- 
dren should have plenty of milk, and bread and butter for 
breakfast and tea ; and roast or boiled meat with gravy and 
light vegetables for dinner, with some light farinaceous and 
egg pudding well sweetened. With regard to quantity, the 
only rule to be enforced is this — let some reliable person be 
always present at meal-times to see that the food is taken 
leisurely, and properly masticated, and if this be done very 
few children will take too much. Some children require 
more than others, but, if the meals are not hurried, the 
healthy appetite is satisfied at the proper time and is a far 
better indicator than any arbitrary rule can ever be. Food- 
bolters are the children that get into trouble from over- 
feeding. They steal a march upon their stomachs, and 
before they feel satisfied they have taken too much. For 
such, the old adage to leave off with an appetite is needful, 
but it is not the teaching of physiology. In the same way 
with children's likes and dislikes ; if the rule given above 
be observed, what a healthy child likes it will usually 
digest, what it dislikes will disagree. It is of course assumed 
that its experience lies well within the range of wholesome 
articles of diet. Take the case of fats and sugars, for instance. 
Nearly all children dislike fat, and are equally fond of sugar. 



48 DISEASES OF CHILDREN. 

It is an unquestionable fact that rich articles of food easily- 
upset them ; what, therefore, can be the sense of insisting 
on children eating fat? The liking for it comes at the 
proper time. On the other hand, children are fond of 
sugar, and make up with it where they fail in fat, and there 
is no evidence whatever that sugar is harmful when taken 
at proper times. To take sweets at all hours of the day at 
the expense of the proper meals is one thing, and to be 
strictly forbidden ; the moderate consumption of saccharine 
material at meal-times, whether it be in the form of sugar 
or good wholesome preserve, is quite another thing, and as 
certainly to be recommended. It is often stated that sugar 
is bad for the teeth, but experience proves what after all is 
only common-sense physiology — that sugar is only harmful 
in proportion as it leads to indigestion, and to consequent 
disorder of the salivary and buccal secretions. In other 
words, it is abuse, not use of saccharine substances that is 
to be deprecated. 

No doubt there are some children the functions of whose 
stomachs seem to be topsy-turvy. Everything they ought 
to like disagrees with them, and they live — but rarely 
thrive — upon most unwholesome diet. Some will be almost 
entirely carnivorous, some cannot take milk, others resent 
farinaceous puddings, and so on. But it will generally be 
found that where this is so the early education of the 
stomach has been at fault, and patient correction will bring 
it round. Mothers and nurses will say a child cannot take 
this and that, because they have administered the thing 
improperly. But if the medical man insists on a return to 
such diet under strictly detailed conditions — nay, sometimes 
it may be necessary to make it one's business to see a child 
at its meals, and note what it is eating — no difficulty what- 
ever will be experienced in its digestion. 

One or two points concerning the administration of food 



INTRODUCTION. 49 

to infants may be alluded to here, as akin to the question of 
diet, and upon which the success of all diet depends. 

In the first place it is necessary to insist upon the ob- 
servation of the most scrupulous cleanliness. The more 
simple the feeding apparatus, the better. 

Tubes should never be used. They cannot be kept clean 
any length of time, even when the greatest care is exer- 
cised, and, when slightly neglected, as is too frequently the 
case, are often the cause of digestive troubles and wasting. 

The bottle and nipple are much to be preferred. Of these 
there should be two each. The nipples should be soft and 
flexible, of a conical, not bulbous, shape so that they may be 
easily everted. After each nursing the nipple must be 
immediately removed from the bottle, cleansed externally 
by rubbing with a stiff brush wet with cold water, and then 
everted and treated in the same way. It must then be placed 
in cold water and allowed to stand in a cool place until 
the following nursing. 

The bottle for an infant under three months ought to have 
a capacity of four to six fluidounces, and be of flint glass.* 
Immediately after using, it must be scalded and cleaned 
with a brush. It should then be filled with a solution of 
one of the salts — bicarbonate or salicylate — of sodium and 
allowed to stand until next required. It should then be 
thoroughly rinsed with cold water. 

Of food warming and food preservation it may suffice to 



* The editor would draw attention to the " Graduated Nursing 
Bottle," made after his suggestion by Mr. J. J. Ottinger, of 
Philadelphia, and already referred to under the head of " Ster- 
ilization." The accompanying figure shows the advantages of 
this feeder. Its internal surface, presenting no angles, is readily 
kept perfectly clean, and the advantages of the graduated scale 
are quite apparent. For further description, see " Hygiene of the 
Nursery," 2d Edition. 



Fig. 2. 




50 DISEASES OF CHILDREN. 

say that of all food warmers Grout's is the simplest and the 
best. It consists of a well, sunk in a cubical hot water tin, 
and in it food or water can be kept at a comfortable heat all 
night, without any supervision whatever. But like all appa- 
ratus of this kind it is a good incubator, and food placed in 
it may become sour. In this statement lies the kernel of 
the matter, and the golden rule is to keep all the ingre- 
dients of the food separate, and to measure, mix and warm 
each portion just at the time of administration. There is 
no objection, though, to keeping water hot in a " food 
warmer." 

It may be sometimes necessary to preserve milk for some 
hours for a journey, etc. The best plan for carrying out 
such an object is to procure "fresh condensed" or "steril- 
ized milk." Ordinary condensed milk, too, is of great value 
under such circumstances. In traveling either by cars or 
by steamboat, hot water can easily be obtained, so that the 
child has the advantage of the same quality of food from 
the beginning to the end of its journey. 



PART I. 
DISEASES OF THE DIGESTIVE SYSTEM 



i. DISEASES OF THE MOUTH AND THROAT. 

Dentition and its Derangements. — The milk teeth — 
twenty in number — are cut in the following order : The 
two lower central incisors from the seventh to the ninth 
month, often earlier and sometimes later. After a lapse of 
five or six weeks come the four upper central incisors ; next 
come the two lower lateral incisors and the four anterior 
molars. After another interval the four canines appear, 
and last of all the four posterior molars ; the whole set 
being cut by about the end of the second year.* The 
lower jaw is ordinarily a little in advance of the upper. 
But it must not be supposed that there is any strict time- 
keeping in the appearance of the teeth, for, although there 
is a pretty definite order of occurrence, the lower central 
incisors may appear early or late, and the others may follow, 
sometimes several at once, sometimes with long intervals 
between them. It often happens that the four central inci- 
sors come, then follows an interval, and then steadily onward 
come all the rest save the last four molars, the appearance 
of which may, even in healthy children, be deferred for three 
or even six months over the average age of two years. 

* For a more detailed description of the eruption of the milk teeth, see 
" Diseases of Digestive Organs in Infancy and Childhood." — Starr. 

51 



52 DISEASES OF CHILDREN. 

Dentition is usually held to be the cause of many ailments, 
but to what extent it is really so is doubtful. The time of 
dentition is one of transition. A uniform and bland diet is 
changing for one of greater variety, and the attacks of fever, 
diarrhoea and vomiting, which are so rife at this time, are 
more satisfactorily explained by indigestibility of food than 
by some occult influence of tooth-cutting. This much, 
however, may be allowed : that the growth of a child is one 
of stages ; that there are periods during which unusual 
progress is made ; and that the period of dentition is one of 
these. Increased activity of all the physiological processes 
at work, necessarily implies greater risks of friction between 
one organ and another, or even of a regular break-down. 
Excessive energy, if not properly regulated or adequately 
expended, is liable to lead to an explosion of some sort or 
another. Some such general hypothesis as this, must hold 
good for the instability of working which is common in all 
the viscera during the first dentition, and to a less extent 
during the second dentition, and in the years which usher in 
puberty. In this general sense, the time of dentition is, no 
doubt, a time of peril. The mortality is high, and disorders 
of many kinds: — convulsions, bronchitis, pneumonia, diar- 
rhoea, etc. — each claim victims. But this is not solely a 
consequence of the eruption of the teeth, but a part of a 
general activity of growth and development, to which den- 
tition and morbid phenomena both in a sense respond. 

Still there are, no doubt, certain minor evils attending 
dentition, which require at least a mention. Some chil- 
dren are remarkably susceptible to " colds" under such 
circumstances — that is to say, as each tooth comes through 
the gum the child suffers from coryza ; the eyes and nose 
run ; there is much sneezing, and perhaps a little cough. 
There may be at the same time pyrexia, and the bowels 
become irregular. Some get a>harp attack of fever (temp. 



DISEASES OF THE MOUTH AND THROAT. 53 

103 or 104 ), the cheeks flushing, the lips and tongue 
becoming bright red, and the child becoming restless and 
fretful. Some have diarrhoea at these times ; others, again, 
have convulsions, and still a larger number are threatened 
with them, showing wildness and excitement of manner, 
irregularity of muscular movement and temporary carpo- 
pedal contractions or strabismus. Most children have an 
excessive dribbling of saliva ; frequently bite anything they 
can put their hands on, and there may be a little superficial 
ulceration of the mouth. Indigestion is common. The 
child suffers from heartburn and offensive eructations, while 
lichen urticatus (strophulus) appears upon the skin. Con- 
vulsions are not a common ailment of dentition, per se, 
and it is the opinion of West, Henoch, and many other 
observers, that they are but seldom seen except in asso- 
ciation with rickets. 

In the treatment of these varied conditions, to be fore- 
warned is to be forearmed, and the timely management of 
slight disorders may in all probability arrest more serious 
evils. To control the excess and irregularity of muscular 
movement, is probably to avert the development of a pro- 
nounced convulsion. The "cold" neglected becomes a 
bronchitis or pneumonia ; the indigestion leads to vomiting 
and diarrhoea; the slight feverishness to severe pyrexia. 
The treatment may seem somewhat empirical, nevertheless, 
simple means suffice in most cases; carpo-pedal contrac- 
tions and other threatenings of convulsion, will often 
speedily subside on the action of some mild aperient — a 
small dose of calomel, or two grains of hydrarg. c. creta 
with a similar dose of pulv. rhei. The coryza is suitably 
treated by a little chloride of ammonium and ipecacuanha ; 
the fever by a drop of tincture of aconite, or a little sali- 
cylate of sodium with acetate of ammonium, as in the fol- 
lowing formula : — 
5 



54 DISEASES OF CHILDREN. 

R. Sodii salicylate, gr. xxxvij. 

Ext. glycyrrhizae pulv., gr. xij. 

Liq. ammon. acet., f ^ iij . M. 

SlG. — From one-half to one teaspoonful, diluted, every three or four hours. 

Or, 

R . Ext. jaborandi fid., f gj. 

Syr. limonis, f^j. 

Liq. potass, citrat., q. s., ad f^iij. M. 

SlG. — From one-half to one teaspoonful every two to four hours. 

If the pyrexia be severe, and there be any threatening of 
convulsions, and a tooth seems to be worrying the gum 
close beneath the surface, there can be no harm in using the 
gum lancet to relieve the upward pressure ; at the same 
time bromide of potassium or sodium and some saline, 
such as citrate of potassium, should be given internally, 
either as a nocturnal draught, or twice or three times a day. 
Elixir of the valerianate of ammonia is also very useful. 

The subject of dental decay, although one of interest to 
all who see much of the diseases of children, is hardly 
within the province of this book. Some children undoubt- 
edly bolt their food on account of toothache ; and the pre- 
sent dental practice of preserving the temporary teeth by 
stopping is much to be commended, for it unquestionably 
aids in the prevention of digestive disturbances, and at the 
same time favors the proper development of the permanent 
teeth. 

The second dentition commences about the sixth year, 
with the eruption of the first molars ; next in order come 
the central and lateral incisors, the first bicuspid, the second 
bicuspid, the canines and second molars, at intervals of a 
year or so. 

The thirty- two permanent teeth are cut in the following 
order, the figures representing years : — 

Molars. Bicuspids. Canine. Incisors. Canine. Bicuspids. Molars. 
25-I3-6 J IO-9 J II I 8-7-7-8 I II I 9-IO I 6-13-25 I 



DISEASES OF THE MOUTH AND THROAT. 55 

There can be no doubt that this also is a time of hazard 
to the child, but there is less risk now than during the first 
dentition ; nor is there, indeed, the same reason for the 
occurrence of any special disorders. There is no change 
of diet, no special development which begins at this time, 
at all comparable to that which takes place during the first 
dentition. Nevertheless, there is abundant evidence that 
ill-health occurs and is attributable to the eruption of the 
permanent teeth, especially the fifth -year molars.* Dr. 
Gowers, from an analysis of a large number of cases of 
epilepsy, shows that the numbers rise at seven years of age 
— the commencement of the second dentition — and fall 
again in the next few years, preparatory to a further rise at 
puberty. Still it seems not unlikely that this should be 
referred to the extra calls which, at this time of life, are 
made in any case upon brain and body, rather than to the 
process of dentition ; and, apart from epilepsy, chorea, and 
neurotic diseases generally, there are none which attach 
themselves peculiarly to this period. 

Dr. Goodhart states that Mr. Nunn, consulting surgeon 
to the Middlesex Hospital, tells him of more than one case 
of epileptiform convulsions occurring during second denti- 
tion within his own knowledge, and apparently arrested by 
the lancing of the gums. Mr. Nunn has also seen corneal 
ulcers of similar origin ; and Rilliet and Sanne insist upon 
the occurrence of various neuralgic affections of head and 
a nervous cough (particularly in girls), and a lienteric 
diarrhoea. 

The American editor has frequently seen cervical adenitis, 
unquestionably due to the eruption of the fifth-year molars, 
and which quickly subsided when the swollen gums were 

* For further details upon this subject, see Starr, "Preliminary Study of the 
Relation Between the Eruption of the Permanent Teeth and the Ailments of 
Late Childhood," The Physician and Surgeon^ January, 1887. 



$6 DISEASES OF CHILDREN. 

lanced. There is also a condition that can best be described 
as "general debility" which very frequently occurs at this 
time, and for the treatment of which an efficient jneans is 
the lancing of the teeth over the swollen gums. 

Stomatitis. — Several forms of this affection are met with 
in childhood, namely: Catarrhal stomatitis, Aphthous stoma- 
titis, and Ulcerative stomatitis. 

Catarrhal Stomatitis consists of an erythema of the 
mucous membrane of the mouth, either limited to circum- 
scribed spots or extending over the whole surface. In the 
latter case there is much swelling. The papillae of the 
tongue are enlarged and reddened and its epithelium is 
abraded, while the mucous glands of the lips and cheeks 
are prominent and yield on pressure a drop of mucus. The 
buccal secretion is increased in quantity, acid in reaction, 
thin, or viscid and flocculent, and runs from the mouth, 
producing excoriations of the skin of the lips and chin. 
The mouth is hot and tender, sucking or mastication are 
painful and cold drinks are craved. The bowels are apt to 
be disturbed. 

This condition is produced by hot and irritating food, 
teething, carious teeth and want of cleanliness ; it may also 
arise in the course of the exanthemata, or precede and 
attend more serious affections of the mouth. 

The treatment consists in keeping the mouth clean by 
frequent applications of tepid water, lancing the gums in 
difficult dentition, removing carious teeth, applying a wash 
of borax or chlorate of potassium, and attending to the 
digestion both by diet and appropriate medicines. 

Aphthous Stomatitis. — In this affection a number — 
three or four to twenty or more — of small ulcers appear 
upon the reddened and swollen mucous membrane of the 
lips, cheeks, tongue and gums. They are round or oval, 
usually from one to two lines in diameter, slightly depressed, 



DISEASES OF THE MOUTH AND THROAT. 57 

with a yellowish-white floor and surrounded by a narrow 
ring of deep redness. Sometimes several of them run 
together, forming large, irregularly-shaped ulcers. No 
cicatrices are left on healing. 

The mouth is hot and tender, the tongue is heavily 
frosted, the flow of saliva is greatly increased, and this 
fluid, now acid in reaction, as it dribbles over the parted 
lips, excoriates the skin with which it comes in contact. 
Appetite is diminished, partly on account of the pain inci- 
dent to sucking or mastication and partly in consequence 
of associated gastric catarrh ; cold water is taken freely. 
There is moderate heat of skin, a tendency to constipation, 
restless sleep and irritability of temper. 

Aphthae occur in the course of gastro-intestinal catarrh 
from improper feeding, during dentition, or with measles, 
scarlet fever, whooping cough and other acute diseases of 
infancy. The affection is most common between the sixth 
and fourteenth month of life, and large crops of cases are 
apt to arise together. 

The general treatment comprises careful regulation of 
the diet and a moderate dose of calomel, followed by 
pepsin with dilute muriatic acid if there be much gastric 
disturbance, or by chlorate of potassium and dilute muriatic 
acid if the oral symptoms predominate. Locally a wash of 
chlorate of potassium (gr. x to foj) should be used every 
hour, and if the ulcers do not heal quickly they may be 
touched once a day with a point of lunar caustic. 

Ulcerative Stomatitis has for anatomical lesions paren- 
chymatous inflammation of the gums (ulitis) and ulcerative 
destruction of the investing mucous membrane. The lower 
jaw is more frequently affected than the upper. 

First the mucous membrane becomes red and swollen, 
the portions of the gums between the teeth standing out 
like little flasks and bleeding on the lightest touch. Next 



58 DISEASES OF CHILDREN. 

the edges in contact with the teeth turn yellow or yellowish- 
gray, the tissue softens and gradually breaks down into 
superficial linear ulcers, having gray floors and red margins. 
The teeth are loosened, and sometimes the periosteum is 
destroyed and necrosis of the jaw-bone takes place. After 
a time the ulceration extends to the cheeks, the lips and the 
tongue, and occasionally true noma follows. 

The mouth is hot, the tongue coated, the breath offensive, 
and streams of viscid blood-stained saliva drivel away. 
There is much pain on mastication, and upon this, in great 
part, depends the anorexia. The submaxillary and lym- 
phatic glands of the neck are usually swollen, and the face 
is often cedematous. Debility, fretfulness, and disturbed 
sleep are symptoms, but the implication of the general 
system is trifling. The course is indefinite. 

Ulcerative stomatitis is most prone to develop in feeble, 
rickety and strumous children, in those who are exposed 
to bad hygienic influences, and in those convalescing from 
typhoid fever, measles, and scarlatina. It is never seen 
before the appearance of the teeth, but may occur at any 
age thereafter. It is not contagious, though large numbers 
of cases are apt to arise simultaneously. The plan of treat- 
ment is to improve the diet and general hygienic conditions, 
to administer tonics and stimulants, to keep the mouth clean, 
to make frequent applications of a solution of chlorate of 
potassium, and administer the same drug internally. 

When the ulceration is considerable the ulcerated surfaces 
should be freely swabbed by the medical attendant with a 
saturated solution of permanganate of potassium. Two ap- 
plications of this kind, at intervals of two or three days, are 
generally sufficient ; but, if practicable and necessary, such 
an application might be made daily, and a gargle of the 
ordinary Condy's fluid, half a teaspoonful to a pint — or a 
teaspoonful of the pharmacopceial lotion— should be used 



DISEASES OF THE MOUTH AND THROAT. 59 

frequently, either by syringe or gargle as the age of the 
child may require. Loose teeth should not be extracted 
until a chance has been afforded them of refixing themselves 
in their sockets, or until it is evident that their presence is 
prejudicial to the healing of the sores. 

Thrush is a fungus which grows upon the buccal mu- 
cous membrane and occasionally extends to other parts 
of the digestive tract, such as the oesophagus, the stomach, 
and intestines. The oidium albicans is the name by which 
it has long been known, but Gravitz has called in question 
the previous descriptions,* and has shown that it belongs 
to the widespread moulds, and is identical with the mould 
of wine. It consists of long-jointed threads and spores, 
which, like tinea upon the skin, are sometimes entangled in 
the epithelium only, and sometimes run down in the folli- 
cles. Like tinea, it appears to be contagious. Its frequent 
presence in the mouth is thought to be favored by the acid 
reaction which so often obtains there. It is generally held 
to be a form of stomatitis, but it is not necessarily so. To 
many cases of stomatitis, thrush is superadded. The thrush 
fungus may no doubt itself be a cause of stomatitis, but it 
may and does exist without any appreciable inflammation 
whatever. Tinea of the scalp may exist without exciting 
any inflammation, and thrush likewise. It is thus that two 
groups of cases are met with in practice, those in which 
there is no inflammation, when the disease is readily curable, 
and those in which there is more or less inflammation, and 
where it is dangerous either in itself or as indicating a 
widespread disorder of the digestive tract associated with 
feeble energy. 

In the first group, the affection is prone to attack infants 

* "Zur Botanik der Sorrs," Deutsche Zeitschr. f. Prakt. Med., 1877, No. 20. 



60 DISEASES OF CHILDREN. 

within the first month of birth — the small and spare ones 
especially, who take the breast badly or are being fed arti- 
ficially. Looking into the mouth, a layer of thin white 
membrane is seen covering the arch of the palate ; perhaps 
a little similar material is dotted in opaque white specks 
over the sides of the tongue — the mucous membrane around 
being quite pale and free from inflammatory action. Under 
the microscope the white layer is found to be composed of 
oil globules from the milk, squamous epithelium, and the 
spores and mycelium of the fungus. A better adapted diet 
and the frequent application of glycerinum boracis to the 
affected parts will cure the disease. The mouth should be 
carefully wiped out after each meal with soft rag or well- 
wetted wool, and glycerinum boracis applied afterwards in 
the same way. Cases are on record in which the contagion 
appears to have been conveyed from one child to another 
by means of spoons, bottle-nipples, and such like ; and 
though it is doubtful whether vigorous children are liable 
to be contaminated, the possibility of such a thing should 
enjoin the most scrupulous cleanliness. 

In the graver cases, which form the second group, dry- 
ness and congestion of the mouth are superadded; the 
papillae of the tongue are prominent and vascular, and the 
fungus occupies a larger area and is of more luxuriant 
development. The dorsum of the tongue will be more or 
less covered, and the lips, cheeks and edges of the tongue 
are also affected with milky-white points of the growth. 
Superficial ulceration is also often present. 

In all cases of thrush, but in these bad cases more espe- 
cially, there is a liability to an erythematous rash, or even 
a superficial dermatitis, about the buttocks and genitals. 
Mothers are fond of telling that their children have had the 
thrush, and that " it has gone through them " — a popular 



DISEASES OF THE MOUTH AND THROAT. 6 1 

impression which, although not wholly true (for it is but 
rarely that the fungus is present about the anus, or even in 
the intestines), is not altogether erroneous. 

What actually happens is probably this : The presence 
of thrush indicates a disordered state of the secretions of 
the mouth. The state of the tongue and faucial mucous 
membrane is, to some extent, an indication of disorder all 
along the gastro-intestinal tract with which erythema, inter- 
trigo, eczema, or superficial dermatitis — by whatever name 
the disease may be known — is associated. This is supposed 
to be due to acrid discharges from the bowels and to abnor- 
mally irritating qualities of the urine. But, from the nicety 
and rapidity with which its recurrence can, in some children, 
be controlled by the regulation of the starchy matters in the 
food, it is probably due to a general blood condition mani- 
festing itself in those parts where local surroundings — such 
as warmth, moisture, and irritation — favor its outbreak. 

Severe thrush maybe attended by fever, and is usually a 
sequela of chronic diarrhoea or vomiting, prolonged starva- 
tion, and fevers of all kinds — but particularly when asso- 
ciated with gastro-enteritis and dentition. It may also 
present itself after any severe illness, such as any of the 
exanthemata may produce. This form of the complaint 
denotes extreme exhaustion, and the general condition 
rather than the local state calls for treatment. It is, more- 
over, a case rather for dieting than for drugging. The 
details must be suited to the special circumstances ; but 
the body-heat must be kept up by all possible means. The 
food should be nutritious, and given frequently in small 
quantities. Stimulants, such as brandy or rectified spirit, 
in twenty-drop doses every three or four hours, are generally 
most beneficial. No care is too exhaustive for such cases. 
The directions for food, stimulants, drugs, etc., should all 
be written precisely on paper, and frequent visits should be 
6 



62 DISEASES OF CHILDREN. 

made during the day to insure that they are intelligently 
carried out. 

In addition, small doses of carbonate of ammonium or of 
chlorate of potassium should be given every three or four 
hours, and the glycerinum boracis be applied frequently, as 
before described. 

An admirable mouth-wash is : — 

R. Sodii salicylate, 

Sodii borat., aa gr. x 

Acid, carbol., gr. j 

Glycerinse, f 3 ij 

Aq. rosse, q. s. ad f Jj. M. 

SlG. — Use frequently as a wash. 

Noma or Gangrenous Stomatitis is characterized by 
the appearance of an indurated swelling in the cheek, which 
rapidly extends and mortifies, perforating the soft parts, 
and, if unchecked, destroying all the tissues within its reach. 
In this way a circular eschar is produced in which the 
entire cheek may disappear. The ulceration extends into 
the orbit or on to the neck, the underlying bone being 
killed and the teeth dropping out. The disease commences 
on the inner surface of the cheek as a livid, red, painful 
induration, which soon extends through its entire thickness, 
and appears externally, the skin becoming red, tense, and 
shining. The area of redness gradually extends, the parts 
around become cedematous, and the central part gangren- 
ous. An irregular ulcer is now seen in the centre of the 
affected mucous membrane, covered with a gray or yellow- 
ish-gray slough, which, by means of lateral and deep exten- 
sion, rapidly kills all the soft parts, and ultimately produces 
a circular perforation in the cheek. The disease often 
appears to undergo a temporary arrest, but only to begin 
again shortly in the edges of the ulcer. The indurated 
swelling makes opening of the mouth a difficulty, and there 



DISEASES OF THE MOUTH AND THROAT. 63 

is copious dribbling of fetid saliva. The gangrenous aspect 
of the sore, the blackened teeth showing the sloughing 
gums beneath, and the excessive fetor, conspire to make a 
picture so repulsive that even the death of the child — which 
hitherto has resulted in over 75 percent, of the cases — adds 
but little to its intensity, and comes in most cases as a wel- 
come relief. After the formation of the slough there is little 
pain attending, the child being usually prostrate and lethargic. 

The constitutional symptoms are not always alike. Oc- 
curring as it does so often in anaemic and exhausted children 
after measles and such like, malaise and fever (101 to 104 ), 
though usually present, may be overlooked ; and the drib- 
bling of fetid saliva and the livid induration of the cheek 
are the first signs to attract attention, the child soon after 
becoming prostrate and drowsy. But it occasionally hap- 
pens that the gangrene may progress even to the destruc- 
tion of the greater part of the cheek, the child all the while 
sitting up and playing with its toys ; in such cases the fatal 
result may be due to the poisonous exhalations which the 
child breathes — perhaps to the putrid saliva which it swal- 
lows. In a minority of cases the sloughing stops, or is 
arrested by treatment ; the edges of the ulcer granulate, and 
the child recovers. It is worthy of note that when this 
happens the gaping aperture left by the gangrene contracts 
to veiy small dimensions ; but the perfection of the cure is 
somewhat marred by the frequent occurrence of corre- 
sponding distortion of the angle of the mouth, or the lower 
eyelid — or, by the inconvenience caused by adhesion of the 
cheek to the gum or bones. 

Morbid Anatomy. — But little can be added to the clini- 
cal history. A black-edged, foul-smelling ulcer extends 
over more or less of one cheek. Its base is formed by what 
remains of the gangrenous tissue of the cheek, by remnants 
of gum tissue, necrotic jaw, and discolored and even ulcer- 



64 DISEASES OF CHILDREN. 

ated tongue. The soft parts being so extensively involved 
in the sloughing process, and having, in addition, usually- 
received a copious dressing of some strong escharotic, are 
not in a state favorable to any minute examination ; but, so 
far as I have seen, there is comparatively little accessory 
oedema of the parts surrounding the disease after death ; 
nor need there be any formation of purulent thrombi in the 
facial or other veins of the neck ; but abscesses in the lungs 
and pyaemia from this source are occurrences which are not 
infrequent, and should be remembered and searched for. 
Rilliet and Barthez describe the neighboring lymphatic 
glands as enlarged. The swelling is not usually great, but 
they may be considerably injected. The author is inclined, 
indeed, to make a contrast between the morbid appearances 
of facial carbuncle and those of the disease we are discuss- 
ing, in this way, that the former is associated with much 
serous infiltration and tendency to purulent thrombosis, the 
latter not. In most cases there is a diffused form of bron- 
cho-pneumonia about the root and bases of the lungs, and 
death is caused by a lesion of this kind, or by the drowsi- 
ness and exhaustion to which allusion has been made. 

Etiology. — The most important fact that has been ob- 
served under this head is the large proportion of cases that 
have been preceded by measles.* Scarlatina, typhoid fever, 
diphtheria, pneumonia, unwholesome living of all kinds, 
share — but to a less extent — the bad name which attaches 
to measles. German authors insist also upon the frequency 
of its occurrence after the administration of mercurials. 
West records one such case out of ten ; but it is probably 
an infrequent occurrence in England or America. 

The disease is most prevalent in the spring and autumn. 
It may occur at any age between two and twelve years, but 

* Sanne gives 1 10 out of 226 cases. 



DISEASES OF THE MOUTH AND THROAT. 65 

is most common from two to five ; and, according to Vogel, 
more frequently attacks girls than boys. 

Treatment. — The great fatality attaching to noma must 
not lead us to a desponding neglect in treatment; on the 
contrary, there are certain cardinal aims to be attained, 
which, though difficult of achievement, are not, let us hope, 
impossible or impracticable, and which, if they can be 
reached, may lessen the mortality. It has been held by 
most writers up to the present time that the disease is a 
constitutional blood condition, not a local one, and the 
evidence of this has been sought and found in its occur- 
rence after the exanthemata and in the broncho-pneumonia 
and occasional pyaemia which usher in death. But condi- 
tions of exhaustion are just those in which nowadays risks 
of local contagion are considered paramount. It could be 
shown, from numerous inspections, that severe operative 
procedures about the mouth — such as removal of the 
tongue — gangrenous ulcers about the throat, etc., are par- 
ticularly prone to be followed by a gangrenous form of 
broncho-pneumonia. It is only too obvious also that in 
these cases, as in noma, there is every probability that sep- 
tic matter is carried along the respiratory passages. Lastly, 
the occurrence of abscesses in the lungs, if not explicable 
in this way, is intelligible as resulting from transmission of 
septic matter along the branches of the external jugular 
vein to the right side of the heart and the lung. 

Thus, then, the prominent symptoms of the disease 
admit of interpretation by means of some virulent local 
'poison. Attention must be drawn to another point in its 
history, which is suggestive in this respect, namely, the fact 
that the gangrene of the face may produce very extensive 
destruction while yet the child is at play with its toys, eats 
and drinks well, and appears but little affected. In this 
respect these cases bear some resemblance to some cases of 



66 DISEASES OF CHILDREN. 

charbon, and also of diphtheria. Like charbon, it is a dis- 
ease in which microorganisms exist in the blood, and from 
the favorable results of vigorous local treatment in this 
affection we have encouragement for the same efforts in the 
disease under discussion. 

It is necessary to add that all writers recommend local 
treatment, although it has not been attended with any re- 
markable success. 

Attention must be paid to two points: I. The destruc- 
tion of the local virus ; 2. The prevention of the passage 
of fetid matter into the respiratory passages. 

Upon the first head there is nothing new to say. Dr. 
Goodhart states that he can only repeat that in anthrax, 
which has many features of similarity, the disease has been 
treated early by free excision and subsequent cauterization, 
and in several instances with success. That appears to be 
the recognized practice for all such cases as Guy's, and he 
strongly recommends a similar procedure for noma, and 
insists upon its early application. Supposing, as is com- 
mon, that gangrene has already commenced, and the disease 
has gone too far for excision to be practiced, all possible 
sloughing material should be removed, and the surfaces, 
together with the edges of the ulcer, freely cauterized — 
either by strong nitric acid, or by one of the many conven- 
ient forms of cautery now in use — and afterwards dusted 
with iodol or iodoform. 

The passage of foul material into the air-passages may 
be at any rate partially controlled by keeping the child on 
its stomach, inclined to the affected side, and the head 
dependent over a pillow. The saliva and discharges tend 
thus to run outwards rather than backwards. The diseased 
part must be frequently and freely smeared with some 
tenacious disinfectant, such as terebene, oil of eucalyptus, 
or iodoform ointment, and frequently syringed with a lotion 



DISEASES OF THE MOUTH AND THROAT. 67 

of chlorinated soda. Should these various remedies prove 
unsuccessful, it might be well to perform tracheotomy, and 
thus allow of respiration below the sources of contagion, 
rather than run the risk of broncho-pneumonia. Twenty- 
eight fatal cases are mentioned by Dr. West from his own 
practice and that of MM. Rilliet and Barthez, no less than 
twenty-five of which died from broncho-pneumonia. It is, 
however, proper to state that MM. Barthez and Sanne give 
it as their opinion that the broncho-pneumonia is often the 
primary affection. 

While these measures are adopted the child's strength 
must be kept up by the administration of nourishing liquids 
and stimulants. Should there be any difficulty in intro- 
ducing them by the mouth, they may be given by a tube or 
catheter passed through the ulcer, or along the floor of the 
nose. As a last resource nutritious enemata may be used, 
recourse being had to artificial digestion of the substances 
injected. Chlorate of potassium and iron should be ad- 
ministered. 

Ulceration of the mouth is also met with under other 
circumstances, of which syphilis and whooping-cough may 
claim special mention. Syphilis in children may be either 
congenital or acquired. Acquired syphilis is rare, but when 
it occurs it may be associated, as in the adult, with consider- 
able soreness and superficial ulceration of the tongue, and 
with mucous tubercles about the angle of the mouth. 

Here is such a case: A boy, aged six, who had never had 
any previous illness, had complained of pains in his limbs 
for a fortnight. He had enlarged cervical glands, a macular 
syphilide all over the trunk, and injection of the fauces with 
ulceration of the left side of the uvula. There were condy- 
lomata about the scrotum and anus. His mother had had 
an ulcerated throat; but no other source for the inoculation 



68 DISEASES OF CHILDREN. 

could be traced ; nor was there any evidence of a chancre. 
He was treated with gray powder, the condylomata being 
dusted with calomel, and he rapidly improved, save that, 
temporarily, he lost a good deal of his hair. 

Congenital syphilis in its later phases is apt to show 
itself by intractable ulcers about the tongue, mouth or 
palate. 

Thus, a boy, aged four, who had snuffles badly when a 
child, was brought for a serpiginous ulcer on the dorsum of 
the tongue, the centre of which was raised and warty. The 
ulcer slowly healed under iodide of potassium and iodide 
of iron. He was also suffering from syphilitic choroiditis 
and retinitis pigmentosa. In another boy a large ulcer de- 
stroyed the fraenum linguae, and covered part of the floor of 
the mouth. 

In another case, a girl, aged twelve, with depressed nose, 
thick alae nasi, fissured lips, and pegged teeth, had a deep 
perforating ulcer of the hard palate, and ulceration of the 
right pillars of the fauces. Sometimes, as in adults, the 
whole of the soft palate is destroyed, the part becoming 
cicatrized, and the thickening extending to the fauces and 
larynx. 

Treatment. — All such cases, whether due to acquired or 
congenital syphilis, should be treated by mercurials. A 
grain or two grains of the hyd. c. cret. may be given once 
or twice a day, or mercurial inunction may be employed if 
the child be quite young. In the late ulcers of congenital 
syphilis, a grain of the iodide of potassium with iodide of 
iron may be given as well, and occasional applications of 
nitrate of silver may also be necessary. 

Ulceration of the Frsenum Linguae in Whooping- 
cough. — This is a frequent occurrence in the convulsive 
stage of pertussis, and a good deal of attention has been 



DISEASES OF THE MOUTH AND THROAT. 69 

directed to it of late years, but except noting its occurrence, 
there is not much to be said of it. The ulcer is usually 
shallow, sharp-edged, and situated on the fraenum close 
under the tongue; it often has a yellowish surface. It 
appears to be in some way associated with the presence of 
the two lower central incisor teeth, as it is never found 
unless they have been cut. It is therefore most probably 
due to the friction of the tongue over their edges when the 
cough is severe or frequent. It is said by Vogel to be 
most frequent between the ages of one and two years, and 
but seldom occurs in older children ; this may possibly be 
explained by some difference in the sharpness of the cut- 
ting edges of the teeth from wear. 

The ulcer heals spontaneously after a time, and does not 
usually require treatment. 

Hypertrophy of the Tongue occurs occasionally. It is 
congenital, and is usually associated with imbecility and 
other evidences of abnormal development, either excessive 
or stunted, such as together make up the condition called 
cretinism. When extreme it causes early death by suffo- 
cation, but when moderate in degree, it does not interfere 
with either respiration or deglutition, and children of one 
or two years old are sometimes seen with a fleshy mass 
visible between the teeth of the half-open mouth which 
characterizes this hideous deformity. 

Hare-lip and Cleft-palate also require mention, because 
in infant life they interfere seriously with sucking. Special 
india-rubber nipples are now made with an obturator, as it 
is called, or flat piece of india-rubber, above them. This 
contrivance, though rather clumsy when put into the mouth, 
fills up the cleft in the palate, and allows suction to be 
carried on, and by it many infants can be reared. Some- 
times artificial feeding can be successfully effected by means 



JO DISEASES OF CHILDREN. 

of a syringe or by carefully regulating the flow of milk 
through a siphon of india-rubber tubing; sometimes slow 
and laborious spoon-feeding alone answers, and sometimes 
nothing succeeds, and the child starves. Such cases often 
require the expenditure of considerable ingenuity and 
thought to combat the many incidental peculiarities which 
occur. In hare-lip, an operation should be resorted to if 
the difficulty in taking food cannot be otherwise overcome. 
In cleft-palate, operative measures are not admissible till 
the fourth or fifth year of life, although in special cases 
they may be undertaken with fair prospects of success as 
much earlier ages. 

Pharyngitis is a very common ailment in childhood, 
and perhaps, as Haig-Brown writes, there is none " about 
which masters and matrons know less, or think they know 
more." The difficulties lie in the fact that this region, rich 
in blood and nervous supply, is "hail fellow well met" with 
all sorts of diseases, and it is not easy to distinguish the 
special rubicundity which attaches to each. To be honest, 
so writes Dr. Goodhart, it cannot be done, at any rate by 
words, though he will not say that there are not more subtle 
criteria learnt from experience which do enable, each for 
himself, after a time, to act, if not always without hesitation. 
Allusion is now more particularly made to a general redness 
of the throat, which may be associated sometimes with 
measles, sometimes with typhoid fever, with septic poisons 
of various kinds, scarlatina, pneumonia, rheumatism, catarrh, 
etc. Some of these are contagious, some are not ; and thus 
it happens that the wise rule to proceed upon in any case 
is to assume that it is so, until by careful examination 
one is at liberty to conclude otherwise. With the in- 
flammation of the tonsils it is allowable to be a little more 
precise. 



DISEASES OF THE MOUTH AND THROAT. J I 

Acute Tonsillitis is not a common disease of childhood, 
if quinsy in adults be taken as the standard of comparison. 
Dr. Goodhart, however, has lately had .a girl of six years 
under treatment who was admitted for a large and very 
deep punched-out ulcer on the left tonsil, which could, he 
thinks, only have originated in acute suppuration of the 
tonsil, and a consequent slough of its anterior part. It was 
so deep that, afraid of hemorrhage, he admitted her to the 
hospital. It speedily healed under tonic treatment and the 
local application of boracic acid and glycerine. A less 
acute form of disease is very frequent. In this the child 
complains of headache, refuses its food, perhaps has a little 
pain in swallowing, and the temperature rises quickly to 
100° or 102°. Henoch notes the occasional occurrence of 
convulsions, but this must be very rare. The tongue is 
furred and often red at its edges, the tonsils are swollen, 
and the whole of the fauces are brightly injected. One 
may suspect scarlatina, but no rash is visible, nor is there 
much enlargement of the glands, and probably the case is 
left as one of doubt, with the prescription of a gentle pur- 
gative of some sort, and the enjoinder of warmth, and a 
light diet for the next few hours. Soon the bowels act, the 
temperature falls, and within a day or two the child is well 
again — with, perhaps, a little undue pallor and want of its 
accustomed energy. Some children are peculiar in exhib- 
iting a tendency to the recurrence of such attacks, just as 
some have a tendency to the recurrence of bronchitis or 
pneumonia; this they cast off as age advances. 

In another set of cases the tonsils are more exclusively 
involved ; they are red and swollen, and upon one or both 
are numerous yellowish-white spots of inspissated secretion 
from the follicles. Sometimes these spots coalesce to form 
more or less of a definite layer which puts on some of the 
appearances of the membrane of diphtheria. This type of 



72 DISEASES OF CHILDREN. 

the disease, perhaps even more than the former, is associ- 
ated with mild symptoms ; and the swelling of the tonsils 
with exuding secretion may often be met with as a tempo- 
rary occurrence, with hardly any appreciable alteration in 
the child's health ; this is particularly apt to occur when 
the tonsils are the subject of chronic hypertrophy. Acute 
ulceration of the tonsils is not uncommon in children as 
the result of bad hygienic conditions and exposure to sewer 
gas, and ulcers from this cause may be either superficial or 
deep. No age is exempt from this risk. If children in a 
house are frequently suffering from sore throat, the drain- 
age and the various pipes in the lavatories, baths, and sinks, 
must be carefully examined. If a child is suddenly noticed 
to have enlarged glands at the angle of the jaw in front of 
the sterno-mastoid, never be content without a thorough 
examination of the tonsils. Ulcers in young children are 
often difficult to see, and elude observation in consequence. 
The chief interest and importance of any acute angina in 
childhood rests upon the fact that we have at once to 
balance the possibilities of its origin — to decide, if possible, 
whether it be simple (that is, non-contagious), scarlatinal, 
or diphtheritic. Now, it is easy to say in general terms 
that the redness of a mere angina is bright and that of 
diphtheria or scarlatina more livid ; that the membrane of 
the one is non-adherent and yellowish, in the other gray 
and adherent, leaving a bleeding surface behind it when 
detached ; that in one there is but little enlargement of 
glands, in the other much ; in diphtheria, albuminuria, in 
follicular tonsillitis none ; in diphtheria much constitutional 
depression, in follicular tonsillitis but little. Such criteria, 
however, are not sufficient for practice. Tonsillitis may 
assume a severe form, as in the following case, and we are 
at once in doubt whether it is not diphtheritic or scarlatinal. 
A boy aged six was admitted into Guy's Hospital for stone 



DISEASES OF THE MOUTH AND THROAT. 73 

in the bladder. A day or two before he was to have been 
operated upon he became feverish, then very ill, and he 
died rapidly. At the inspection both tonsils were found to 
be swollen and boggy from diffuse suppuration. 

On the other hand, diphtheria may be exceedingly mild, 
the membrane but little, the constitutional disturbance actu- 
ally none, and the practitioner flinches from pronouncing 
an opinion, with all that it involves. We all frequently see 
a prevalent tonsillitis of no specific character, but which has 
been here and there associated with marked diphtheria, or 
followed by diphtheritic paralysis. Thus there are no ail- 
ments which more require a calm, circumspect judgment 
than sore throat and tonsillitis. Every possible evidence 
must be weighed — not only that derived from such observa- 
tions as have been suggested, but also that drawn from the 
general surroundings of the patient. This will involve 
inquiries concerning the child's playmates ; its school ; the 
house in which it lives ; the health of all with whom it in 
any way comes in contact ; the health of the neighborhood ; 
the drainage ; the rainfall, and perhaps even the direction 
of the wind. After this — having exhausted as far as can 
be the sources of evidence — one of three courses is open 
to us : to call the case diphtheritic or scarlatinal, to call it 
simple angina, or to say the nature of the disease is uncer- 
tain. It is much better to confess to some uncertainty than 
to make light of a complaint which, perhaps, is subse- 
quently proved to be of scarlatinal or diphtheritic nature. 
Haig-Brown gives evidence to show that follicular tonsil- 
litis is sometimes possessed of contagious properties. 

If one distinction may be singled out as less likely to 
mislead us in any disputed case, it is to be elicited from the 
attentive observation of the behavior of the membranous 
formation about the tonsils or fauces. No doubt it is true 
for most cases in which membrane forms, that in simple 



74 DISEASES OF CHILDREN. 

follicular tonsillitis it is non-adherent — is easily detached or 
expressed — and the surface beneath it is intact. In diph- 
theria the membrane is adherent, the surface beneath raw 
and often bleeding, and this even for cases where the con- 
stitutional symptoms are almost none. 

Chronic Tonsillitis and Hypertrophy of the Tonsils 
are almost sufficiently described by their nomenclature. 
The tonsils are seen to bulge into the fauces, either pushing 
the pillars forward, or emerging half pedunculated between 
them as pale red bodies, with a trabeculated and pitted sur- 
face, often studded with a yellow secretion which exudes 
from the mouths of the follicles. It is an affection which 
comes on insidiously. When it has made some progress, 
the throat is liable to recurrent attacks of a mild form of 
inflammation or catarrh ; it is but seldom that the increase 
in size dates definitely from an acute attack. There is a 
good old pathological axiom that for one chronic disease 
which follows an acute one, there are many which take an 
opposite course, and this is a good illustration of the rule ; 
at the same time, the occasional origin of chronic enlarge- 
ment in repeated attacks of pharyngeal catarrh cannot be 
denied. Nor is this a condition which is certainly strumous. 
It is often associated with thick lips and stunted, ill-formed 
features, which have something of the ugly type of struma 
in them ; but any decided strumous affections, such as 
glandular abscesses or the like, are rare. Its march is very 
uncertain ; increasing under the stimulus of an acute attack 
of tonsillitis, it will remain stationary or retrogress for a 
time, and then again advance. Children generally " grow 
out of it," and at fourteen or fifteen years of age it ceases 
to be a disease of any importance. Rilliet and Sanne note 
that it is not uncommon to find a prompt reduction in the 
size of the tonsils after the first menstruation. It is, of 
course, sometimes continued into adult life, and sometimes 



DISEASES OF THE MOUTH AND THROAT. 75 

causes trouble in young adults in the same way as in chil- 
dren — viz., by inducing repeated attacks of sore throat. 
It is a particularly troublesome affection in those who have 
a voice for singing. It is associated with certain symp- 
toms : Firstly, it leads to snoring when the child sleeps — 
not a matter of much concern. Secondly, to deafness, from 
the pressure upon the orifices of the Eustachian tubes, and 
the associated hypertrophic or inflammatory changes which 
take place in the surrounding mucous membrane. This is 
of importance, because such children often appear dull and 
stupid, simply because they are deaf. It interferes, too, with 
free vocalization, and gives a nasal twang to the voice. It 
causes a frequent cough. Lastly, by partial occlusion of 
the air-passage, the lungs fill badly, and the chest becomes 
distorted ; and, it is said that from the want of full use the 
nostrils contract, the upper jaw fails to develop, and, in con- 
sequence, the arch of the palate remains high, and the teeth 
become cramped from want of room. The chest becomes 
pigeon-breasted — that is to say, the ribs are flattened in 
laterally, and the sternum and costal cartilages become 
prominent, sometimes quite pointed. This is the natural 
result of interference with the ingress of air to the lungs. 
The respiratory effort continues, but the lungs fail to be 
distended by reason of the obstruction in the throat ; and 
the ribs yield in obedience to the atmospheric pressure 
along their line of least resistance — in other words, at the 
parts of greatest movement — at their junction with the 
costal cartilages backward to their point of greatest 
curvature. 

Treatment. — No treatment is of much avail but excision, 
and if it should appear that any of the more serious conse- 
quences are in progress, this should be at once advised. 
But it is comparatively seldom that an operation is necessary, 
and fortunately so, for parents manifest great repugnance 



y6 DISEASES OF CHILDREN. 

to it. Parrish's food, the syrup of the iodide of iron, and 
cod-liver oil are to be administered internally; the child 
should be sent to the sea or to some healthy farm in good 
country air; the recurrence of attacks of angina can be 
kept in check by local astringent applications, such as 
tincture of the chloride of iron with glycerine, the glyceri- 
num acidi tannici, or powdered alum or boracic acid; and 
the hypertrophy gradually subsides ; it cannot be said, 
however, that any one of the remedies prescribed has any 
constant value. Nitrate of silver, in the stick form, thor- 
oughly applied to the surface and burrowed into the 
enlarged tonsil in several places, once or twice a week, is 
very efficient, and gives little pain. When the enlargement 
occurs in a child eight or ten years of age, massage, by the 
introduction of a finger into the mouth, and pressure over 
the gland externally, for three or four minutes several times 
a day, also acts well. A child can be taught to do this 
himself. These two methods may be combined, and often 
do good service in obstinate cases. External applications 
to the angle of the jaw, turpentine, iodine, iodide of potas- 
sium ointment, etc., have been much recommended by 
some ; but they will rarely be found to be of the slightest 
benefit. 

Relaxed Throat. — Some children are subject to a 
relaxed throat; with a little cold or a little malaise, the 
throat becomes relaxed, as it is termed, and a dry, frequent, 
tickling cough is the consequence. The soft parts are 
a little flabby, perhaps slightly congested. A good old- 
fashioned formula for such cases is a gargle of a glass of 
port wine, with a little cayenne added, or a little perchlo- 
ride of iron in glycerine may be used locally, and a tonic 
internally. The editor has used the following formula with 
great success in these cases : — 



DISEASES OF THE MOUTH AND THROAT. JJ 

R. Tr. belladon., TT^iv-viij 

Tr. nucis vom. TT\,iv 

Acid, nitro-muriat. dil., TT^xyj 

Syr. zingib., f^ ss 

Aquae, q. s. ad f ^ ij. M. 

Sig. — Teaspoonful every two hours for six closes; repeat daily. (For 
a child of 4 years.) 

Hypertrophy of the Pharyngeal Mucous Membrane 
may be mentioned in association with diseases of the tonsils, 
as probably closely allied to the hypertrophy of those bodies, 
and requiring similar treatment. The mucous membrane 
covering the posterior wall of the pharynx, and extending 
upward to the posterior nares, is thickened and often rugose, 
while it discharges an excess of thick mucus, occasionally 
streaked with blood. This condition causes a frequent 
cough, sometimes even vomiting, from the amount of 
mucus discharged, and it is not so likely to disappear as 
the child grows up. 

Dr. Goodhart states in the few cases in which he has 
found it in the post-mortem room accidentally, the disease 
has not been quite that of writers on laryngeal surgery. 
The posterior wall of the pharynx and the posterior nares 
have, it is true, been the particular seat of disease, but the 
mucous membrane covering these surfaces has been thick- 
ened, fleshy, and thrown into velvety, vertical folds or leaf- 
lets. One specimen of the kind he removed from the body 
of a child aged eighteen months. 

It has not happened to him to see many cases during 
life. Whether they all pass into the hands of the surgeon, 
he does not know, but he is inclined to argue that it is less 
common than writers on such special subjects would seem 
to indicate. It is usually described as being associated with 
enlarged tonsils, but again it happened to him contrariwise 
that, in the two best-marked examples of the disease that 
he has seen, the tonsils were of natural size. 
7 



yS DISEASES OF CHILDREN. 

Symptoms. — The child is generally deaf and stupid- 
looking, keeps its mouth half open, and perhaps snores in 
its sleep. There is frequent cough, sometimes even sick- 
ness from the excess of mucus discharged, and the expec- 
toration is occasionally streaked with blood. It is not so 
likely as enlargement of the tonsils to disappear as the 
child grows up. 

Diagnosis. — This is not always free from difficulty ; it 
must be made from the dull aspect, the deafness, the open 
mouth and snoring, particularly if the amount of enlarge- 
ment of the tonsils is not sufficient to account for the 
extent of the symptoms. 

Treatment. — Alkaline lotions should be syringed 
through the nose, and the nasal and faucial mucous mem- 
brane freely swabbed with soda and glycerine. By these 
means crusts are prevented from forming. Astringents 
may be applied to the tonsils and posterior nares, or 
boracic acid powder may be blown up the nostrils. As a 
last resort, the thickened mucous surface must be removed 
by forceps or cautery; and in many cases the relief obtained 
in this way has been most decided. 

Any one of these conditions may originate the disease to 
which the Germans have given the name of pseudo-croup, 
and which appears to be a spasmodic affection of the glottis, 
due to some recurrent catarrh, such as is common in these 
faucial affections. It is described as catarrhal spasm in the 
section devoted to "Diseases of the Respiratory System." 

Retro-pharyngeal Abscess. — The connective tissue be- 
tween the pharynx and the oesophagus and the bodies of 
the vertebrae is prone to suppuration in children, just as 
that of the ischio-rectal region is in adults, and the child is 
then said to have a retro-pharyngeal or retro-cesophageal 
abscess. It is not a common affection; but many cases have 
now been recorded in a long course of years. West gives 



DISEASES OF THE MOUTH AND THROAT. 79 

sixty-eight cases, collected from various sources, and quite 
recently Bokai has added largely to that number. The 
data derived from them show that the disease is mostly 
idiopathic, or without obvious cause. Occasionally it fol- 
lows scarlatina, or the suppuration of neighboring glands, 
and occasionally is dependent upon spinal caries. 

It is not confined to any age ; but as a disease of childhood 
it appears to be more common in infants a few months old. 
No doubt, to this must be attributed the fact that the symp- 
toms are obscure and liable to be overlooked. 

Symptoms. — These somewhat resemble those of large 
tonsils. They are, difficulty in sucking and swallowing — 
perhaps evident pain in swallowing — and snoring respira- 
tion. Sometimes there is pain and rigidity in moving the 
head and neck, and sometimes a diffused swelling of the 
deeps parts under the angle of the jaw. The fauces are 
covered with mucus and occupied by a rounded swelling, 
which pushes forward the soft palate, encroaches upon the 
rima glottidis, and to digital examination is elastic and 
fluctuating. These signs do not all develop at once ; the 
maturation of the abscess is slow, and apart from fretfulness 
and want of appetite, a certain amount of snuffing — which 
is attributed to cold — may be all that is to be noticed. 
During the course of some days (Henoch speaks of ten to 
fourteen or more) — but some develop in two or three days 
(Sanne) — a swelling forms, and pressure signs supervene ; 
first of these being a more pronounced interference with 
deglutition. Choking fits are easily induced, and fluids 
return through the nose. There may be more or less 
dyspnoea. 

Goodhart has once or twice seen a diffuse suppurative 
cellulitis in this region without any tendency to local- 
ization or pointing. Probably no well-defined distinction 
could be made between the two classes of cases ; but the 



80 DISEASES OF CHILDREN. 

fever may be expected to be more severe, the swelling in 
the neck more diffused, and the outlook is decidedly more 
gloomy in the diffuse than in the localized form. 

Prognosis. — If the abscess be opened, the pus evacuated 
safely, and there be no persistent cause in the way of caries 
of the spine, the child may do well ; but so long as the 
abscess remains unopened, it may mature and open spon- 
taneously, and the pus be sucked into the lungs during 
inspiration, and death from suffocation result. 

Treatment. — The abscess should be opened as soon as 
possible, both. to prevent any large increase in size, and to 
avert spontaneous rupture at inconvenient times. The in- 
cision should be vertical, with guarded bistoury, all but the 
point being encased in strapping. 

Cynanche Parotidea. — Mumps will be described under 
the head of "Contagious Diseases." There is, however, 
another form of disease — viz., that which complicates or 
succeeds to scarlatina, measles, typhoid fever, diphtheria, 
etc. It has been supposed, and probably correctly, that 
this form is of septic origin. At any rate, it commonly 
terminates in suppuration, and it is this that must be 
watched, for the abscess will often open into the external 
auditory passage. Pus should be evacuated by an incision 
as soon as it is detected. This disease has sometimes led 
to paralysis of the facial nerve, and it is a serious complica- 
tion of any of the exanthemata or continued fevers, often 
foreboding a fatal issue. The editor has seen a case of 
suppuration of the parotid due to obstruction of the duct of 
Steno by a calculus in a child less than a year old ; recovery 
followed evacuation of the pus by a free incision and subse- 
quent removal of the obstructing body. 

The oesophagus is a part of the alimentary tract which 
may be said to have no pathology, it is so rarely diseased, 
and when it is, a diagnosis is but seldom possible. In a 



DISEASES OF THE STOMACH. 8 1 

work of this kind, therefore, it will be sufficient to mention 
that thrush or diphtheritic membrane may extend along 
the tube ; and that, in rare cases, an acute inflammation is 
found upon the post-mortem table, indicated by thickening 
of the walls, increased rugosity of the lining membrane, 
changes of color of the surface from the usual pale opaque 
white to pinkish or even black, and more or less unevenness 
of surface from loss of substance. These appearances 
must not be mistaken for those of cadaveric origin, which 
are confined entirely to the epithelial surface or to staining 
of the various tissues; and, very rarely, to perforation from 
gastric solution. Acute inflammation may of course be 
met with as a result of swallowing boiling water ; and from 
the same cause, stricture of the tube is occasionally found 
in children of three or four years old. Lastly, it may be 
mentioned that congenital malformations are met with now 
and then. The oesophagus may end in some part of its 
course in a ail de sac ; it has been known to terminate in 
the trachea instead of the stomach ; and there are some 
reasons for thinking that stricture of its cardiac end, a dis- 
ease of adult life, may in rare cases be congenital. Some 
of these conditions admit of no treatment, and are neces- 
sarily fatal ; some admit only of surgical treatment ; and of 
those which are medical — thrush, diphtheria, and the like 
— the rules laid down in other parts of the book will sup- 
ply all the information that is needed. 

2. DISEASES OF THE STOMACH. 
Some of the diseases of the stomach and intestines are 
closely allied. Acute or milk dyspepsia, gastralgia, and 
vomiting are so ; all these being symptomatic or functional 
diseases. They have no morbid anatomy, and for this rea- 
son they are of somewhat uncertain nature. Herein lies a 
puzzle to the student, because the symptoms which to one 



82 DISEASES OF CHILDREN. 

■* 

writer indicate — let us say, for example, acute dyspepsia, to 
another suggest gastric fever, to another perhaps dentition 
fever. Gastralgia may in like manner be, for all we can say 
positively to the contrary, a colic, or a nerve storm in some 
other part of the abdomen, just as well as an actual affec- 
tion of the stomach itself. 

Dr. Goodhart therefore as far as possible avoids the use of 
terms the correctness of which we are not sure of, and 
describes as cases such sets of symptoms as are common 
in childhood, and which are attributed, both popularly and 
professionally, to gastric disorder. 

First of all, let us take a case of fever : gastric fever if you 
will, but that the gastric origin is uncertain ; acute dyspep- 
sia if you will, but even true dyspepsia is doubtful. 

A healthy child of twelve months, with its two lower in- 
cisors cut, ailed for a day or two with feverishness, consti- 
pation, and occasional vomiting. When seen first, it was 
fretful, with a temperature of 100.4 , and a quick pulse and 
full abdomen. The temperature went up to 103 , remained 
up for two days and a half, and then fell rapidly to normal ; 
the tongue was thickly furred, the bowels confined, the mo- 
tions light in color, and there was occasional vomiting. 
The bowels were opened freely by rhubarb and soda, and 
acetate of ammonium was given internally. A week later 
one of the upper incisors was cut. 

Such cases as this are very common. They occur during 
the progress of dentition, but have often no definite relation 
to the eruption of a tooth. They occur, moreover, at the 
time of weaning, before the stomach has become accustomed 
to the change in its dietary. They occur especially after 
errors in feeding. They will sometimes be speedily relieved 
by vomiting, so that there is some reason at any rate for 
considering them of gastric origin. They are somewhat 
erratic in course and duration. Sometimes the temperature 



DISEASES OF THE STOMACH. 83 

will run up quite suddenly at night, and come down again, 
and remain normal, after the following morning, apparently 
in obedience to a febrifuge, but quite as likely in depend- 
ence upon what may be called the initial vitality of the fever. 
Sometimes the pyrexia is more prolonged, and one per- 
haps begins to discuss the question of enteric fever. In 
such cases, the idea suggested by the term infective gastritis 
may contain a germ of truth, and at any rate, in dealing 
with an affection of the nature of which we are quite in the 
dark, some fugacious erythema of the gastro-intestinal tract 
may be suggested as a possible cause of the elevated tem- 
perature. 

In older children something of the same kind happens, 
the fever being associated with an acute bronchitis of the 
larger tubes. 

Emily W. has been a frequent attendant, between the ages 
of two and a half years and six years, with attacks which 
come on quite suddenly, with vomiting, confined bowels, 
delirium, and high fever. In one of these attacks her face 
was flushed, temp. 103 , pulse 160; the tongue thickly 
furred with white fur, and red papillae showing through; the 
respiration rapid, harsh all over, with copious dry rales, but 
no other physical signs. These symptoms are always re- 
lieved by a dose of castor-oil, and in two or three days she 
is quite well again. 

In another class of cases, fever and cough are combined 
with vomiting and purging. A boy of three years was 
brought for fever and cough, which had come on quite 
suddenly, and after which the bowels were loose, and he 
was frequently sick, the attack extending over a fortnight. 
A little rhonchus was audible in various parts of his chest, 
but no other physical sign, and he rapidly improved by 
careful dieting and a simple citrate of potassium mixture. 

The treatment in all these cases is dietetic and aperient. 



84 DISEASES OF CHILDREN. 

In the cases of infants, a teaspoonful of castor-oil may be 
given at once ; in children over two years, small doses of 
calomel and Dover's powder — a sixth of a grain of each 
every two hours, for three or four doses — followed by an 
aperient, is most useful. It may be difficult to explain the 
action of these drugs, but the fever seems to subside more 
rapidly with them than without them. Another good 
mixture : — 

R . Tr. aconit. rad., mjj 

Aquse, q. s. ad f^j. M. 

Sig. — One teaspoonful every half hour until four doses are taken. (For 
a child of two years.) 

This may be repeated once or twice, allowing an interval of 
from two to four hours. 

The prescription containing salicylate of sodium, given 
on page 54, is also a useful febrifuge in these cases. 

In the gastric fevers of older children a couple of grains 
of jalapin with two of calomel, or a piece of Tamar Indien, 
form good and easily disguised aperients. They should be 
followed by such gentle laxatives and alteratives as effer- 
vescing citrate of magnesia, two teaspoonfuls ; the same 
quantity of fluid magnesia ; one teaspoonful of confection 
of sulphur,* or the following : — 

R. Sodii bicarb., ^iss 

Tr. rhei., f 3 ij 

Syr. acaciae, f ^ iij 

Aq. menth. pip., q. s. ad f^iij. M. 

Sig. — Teaspoonful three times daily. 

A tonic is usually necessary afterward, and none is better 
than Easton's syrupus ferri et quiniae et strychniae phospha- 

* Confectio Sulphuris, Br. P., contains : — 

Sublimed sulphur, 4 ounces 

Acid tartrate of potassium, in powder, I ounce 

Syrup of orange-peel, 4 fl. ounces. — Ed. 






DISEASES OF THE STOMACH. 85 

turn ; ten or fifteen drops to half a teaspoonful, in water, 
three times a day. 

Vomiting in children is almost invariably functional. It 
is supposed to be due, it is true, to gastric catarrh, and, 
more or less, catarrh is not improbably present ; but we 
know nothing of this as a demonstrated condition, and it 
is therefore necessary in many cases to treat the symptom 
as the disease. Vomiting is an important affection chiefly 
when it occurs in nurselings and is chronic. For this rea- 
son it is advisable to treat of it according to the age of the 
patient, and to supplement an arrangement of this kind by 
adding a third group of cases in which vomiting is a reflex 
symptom of disease elsewhere. Thus we have : — 

(a) The vomiting of nurselings. 

(b) The vomiting of older children. 

(c) Reflex vomiting. 

(a) Infants from the first day of their birth are subject to 
vomiting, not from disease, but from a perfectly physiologi- 
cal safety-valve action on the part of the stomach. It is 
impossible to adjust the ingress of food so nicely to the 
needs of the organ that just the proper quantity, and no 
more, is taken, and should there be any surplus, it is 
rejected. Many infants "posset" quite regularly, more or 
less, for the first few months of life ; sometimes very soon 
after taking food, when gas is eructated with it ; at others, 
later during the progress of digestion. And as in the mus- 
cular play of an infant's limbs we can see the physiological 
side of what in morbid excess becomes convulsion, so here 
we have a physiological action, which, if uncontrolled, may 
run riot in chronic vomiting. 

All vomiting in infants must be watched. So long as it 
comes on early after taking food ; while the quantity re- 
jected forms but a small proportion of that taken, and the 



86 DISEASES OF CHILDREN. 

child does not suffer in any way in health, no anxiety need 
be felt at its continuance. Should it become increasingly 
frequent, or seem in any way to be in excess, it must be 
taken in hand, and it is generally quite amenable to treat- 
ment. If, on the other hand, it be neglected, it recurs at 
intervals which tend to become shorter and shorter. The 
vomit each time becomes more copious, till, finally, no food 
is retained, the vomited matters lose the well-known char- 
acters of semi-digested food, and a thin, watery, sour-smell- 
ing liquid is discharged instead. The child meanwhile 
gradually changes. Plump and healthy, perhaps, at the 
outset, it loses its color, and its limbs become soft and 
flabby ; it cries after taking its food ; its stomach is dis- 
tended with gas, and painful on pressure, and the bowels 
become confined. The blood fails to be replenished owing 
to the persistence of the vomiting, and little by little the 
child becomes a withered, wasted thing, with dry, often 
scurfy, skin, depressed fontanelle, and pinched pegtop face. 
The surface is cool, the extremities cold ; it is feeble, 
constantly whining, voracious in its thirst ; its mouth and 
tongue red and dry, with thrush dotted about in various 
parts ; and thus it dies starved. The immediate precursor 
and cause of death may be bronchitis and pneumonia, or 
occasionally some thrombosis of the cerebral sinuses from 
thickening of the blood, and slowing of the cranial circula- 
tion, with its semi-comatose condition, or convulsions; but 
these are the necessary results of the enfeebled condition 
brought about by the prolonged starvation. 

An examination of the bodies of such infants shows no 
disease. There may be an excess of mucus in the stomach, 
some pallor, or even some redness or ecchymosis of the 
mucous membrane ; but these things mean very little, and, 
like the brain of an epileptic, it is but exceptionally that the 
stomach of a child that dies of chronic vomiting shows any 



DISEASES OF THE STOMACH. 87 

sign. Thus there is no difference in the result, and but 
little difference between the symptoms, of this disease and 
chronic diarrhoea. The description of the one might well 
read for that of the other. 

Acute Vomiting in infants is of different significance. 
The chronic disease we have just described is unassociated 
with fever; but vomiting may be associated with fever and 
furred tongue, and with either constipation or diarrhoea ; in 
such case it may mean that the child's food has disagreed 
with it ; or that some exanthem, particularly scarlatina, is 
about to show itself; or that some brain mischief is brew- 
ing ; or, perhaps, that some intestinal mischief, intussus- 
ception, for example, has come on. 

These various possibilities must be considered and some 
conclusion arrived at, and this will not often be a matter of 
difficulty when we have mastered the differential features of 
the diseases of which vomiting is a sign. This can only 
be done under each disease as it comes before us, but it 
may be said in short — that the vomiting of indigestion is 
associated with a quick regular pulse and a full stomach, 
and that it is very common ; if diarrhoea be present also, 
the diagnosis is nearly certain. The vomiting which ushers 
in an exanthem is not a common thing in infants, but an 
examination of the throat and glands might help us to its 
elimination. The vomiting of brain disease is associated 
with an irregular pulse, constipation, and retraction of the 
abdomen ; while for intussusception the pale collapsed ap- 
pearance is, perhaps, the best early hint. 

Treatment. — To take acute vomiting first, which from 
previous investigation is ascertained to be due to undigested 
food. If the spontaneous action of the stomach has not 
already done all that is needed, an emetic of ipecacuanha 
wine (a teaspoonful), or five grains of the powdered ipecacu- 
anha root, should be given, and subsequently a dose of 



55 DISEASES OF CHILDREN. 

castor-oil, or half a grain of calomel and a grain of rhubarb. 
The American author recommends equal parts of aquse 
cinnamomi and liq. calcis — a teaspoonful at a time, or more 
for a child of ten months — as a useful and simple remedy 
for acute vomiting. 

A little bicarbonate of sodium and citrate of potassium 
may be given afterward three or four times a day ; the diet 
being restricted. Most of the children in whom vomiting 
occurs have been fed artificially, but in any case it is needful 
to reduce temporarily the quantity of food given. If the 
breast be the medium, then the child must be nursed less 
frequently, and the quantity taken at each meal should be 
diminished. If other food be given, it is to be diluted and 
the quantity strictly regulated in the same way. Probably 
nothing more will be necessary, and the attack will speedily 
subside ; in severe attacks of vomiting and diarrhcea in 
infants, all milk food should be stopped and the child fed 
on whey or thin veal broth for twenty-four hours. This 
has all been fully considered in an earlier chapter. 

The form known as Chronic Vomiting, on the other hand, 
will yield to nothing else than patience. Like chronic 
diarrhcea it is a most troublesome habit to eradicate and often 
keeps the upper hand of all treatment. Yet in no class of 
cases are the results of perseverance more perceptible or 
more satisfactory. Dr. Goodhart has nothing to add upon 
the question of diet to what has already been said under 
the head of diet. The one common error in treatment is, 
want of patience. A child is sick, and the food is judged, 
and possibly correctly, to be unsuited for it. The food is 
changed, but with no better result — something else is tried, 
but still the sickness continues ; and soon, with anything 
and everything that kind friends suggest, the anxious 
mother has run from food to food, and thereby exhausted in 
the process her wits, her energy, and her child. 



DISEASES OF THE STOMACH. 89 

The first thing to attend to is to secure a strong sensible 
nurse upon whom one can rely. There are few more dis- 
comforting or wearying things than a fretful, ailing infant; 
and it is of very little use to undertake the treatment of such 
a case as chronic vomiting or diarrhoea, with a nurse who 
is worn-out and disheartened. It will next be advisable, in 
all probability, to make a clean sweep of all foods, and to 
start afresh on one of the simplest — we will say artificial 
human milk, for example. Whatever may be selected will 
be met with the objection that it has been tried and has failed. 
But never mind, let it be tried again under the strictest limi- 
tations and directions from the medical attendant, and let it 
not be discarded until he has satisfied himself that it is use- 
less. Nor should he be satisfied of this until some approxi- 
mate idea has been obtained of the amount that the vomit 
bears to the food taken. The sickness is seldom arrested 
suddenly by any treatment, so that if the quantity returned 
lessens, the food selected may be doing its work. Having 
chosen our food — be it artificial human milk, digested milk, 
or milk and lime-water, milk and barley-water, whey and 
cream, or cream alone, veal broth, etc. — the next thing is 
to attend to the quantity given and to the method of its 
administration. In the worst cases all bottles must be 
abjured, and the child fed by the spoon only. It may be 
that the stomach will tolerate no more than a teaspoonful 
at a time — never mind, a teaspoonful retained is worth 
more than a tablespoonful vomited — and a good deal of 
nourishment can be administered by teaspoonfuls given 
at frequent intervals. Whatever food is given should be 
cold. The body at the same time is to be kept as warm 
as possible and the child free from the effluvia of its own 
discharges. 

In medicine nothing is better than calomel in doses of a 
sixth of a grain put upon the tongue every three or four 



90 DISEASES OF CHILDREN. 

hours; hydrocyanic acid and bicarbonate of sodium are 
useful, given in combination, or the former may be given, 
as follows : — 

R . Acid, hydrocyan. dil., TT^iij 

Sodii bicarb., gj 

Glycerinoe, ^ ss 

Aq. cinnam., q. s. ad f^iij. M. 

Sig. — Teaspoonful every three or four hours. 

Ipecacuanha in drop doses is recommended by some ; 
arsenic with nux vomica and bicarbonate of sodium by 
others. Arsenic in minute doses, for instance half a drop 
of Fowler's Solution, in a teaspoonful of water three times 
a day for infants, often produces most gratifying results. 
But careful dieting is, decidedly, of more importance than 
any medicine, and upon it must our main reliance be based. 
It frequently happens, in the worst cases, that stimulants 
are necessary, five drops of brandy or rectified spirit being 
given every hour as occasion demands. 

(b) The vomiting of children past the age of infancy is 
most commonly due to indigestion ; occasionally in girls 
it is the precocious development of symptoms well known 
in young adult females as the outcome of hysteria. 
Sudden causeless vomiting in a child of previously good 
health should suggest the possibility of the onset of 
some acute disease, particularly of scarlatina; and, as at 
any other time of life, vomiting may be due to disease 
elsewhere. 

The functional vomiting, alone necessary to be mentioned, 
after what has just been said, is to be diagnosed, as it would 
be in adult life, by its frequency, its quick onset after food, 
the absence of symptoms of any definite illness, and by the 
nervous aspect of the patient. Children affected by it are 
usually from nine or ten to fourteen years. 

(c) Reflex vomiting may be due to meningitis or tumor 



DISEASES OF THE STOMACH. 9 1 

of the brain, to chronic disease of the lungs, to pertussis, to 
dentition, or to worms. The vomiting of brain disease is 
erratic in its occurrence — the tongue is clean, and there is 
an absence of all gastro-intestinal symptoms; there is other 
evidence of cerebral disease, such as headache, or impaired 
muscular power, diminished acuteness of vision, and inter- 
mittent action of the pulse. In disease of the lung, there 
is the cough and emaciation; in pertussis, the paroxysmal 
cough and bloated aspect generally suffice for a diagnosis, 
but it occasionally happens that the sickness is the only ail- 
ment of which complaint is made, the cough being forgotten. 
Dentition and worms have already been mentioned. 

Under the head of treatment, it need only be stated, that 
one is often driven to treat symptoms, and happily with a 
success by no means inconsiderable. 

Ulcer of the Stomach is not very uncommon in new- 
born infants, but is decidedly rare afterward. It occurs 
either as a single minute round ulcer, with a perforating 
tendency as in adults, or as numerous small scattered ero- 
sions which stud the surface of the mucous membrane and 
assume the appearance of ulcerated follicles. The perfo- 
rating ulcer has been ascribed to all the various causes 
which are held to be potent in producing the gastric ulcer 
of adult life, and it is probable that for children after they 
are weaned the pathology of the two may be the same ; but 
for new-born infants, the circulatory disturbances which 
ensue somewhat suddenly at birth, the sudden arrest of the 
placental stream, the gradual development of the pulmonary 
circulation, associated as it often is with partial atelectasis, 
so patently predispose to venous stagnation in the abdom- 
inal viscera as to give much ground for the belief that con- 
gestion and even ecchymosis are at the root of the ulceration. 
The scattered ulceration has been found under such varied 



92 DISEASES OF CHILDREN. 

clinical conditions that it is impossible to attach any definite 
meaning to it, although one may suppose with reason that 
it is the result of some chronic catarrh. 

Symptoms. — Vomiting of blood and melaena are the only 
indications which point to the existence of an ulcer of the 
stomach, in the infant. A healthy child within a few hours 
of its birth who begins to vomit blood and to pass pitchy 
matter per anum, may have a gastric ulcer. More than this 
we cannot say, for the same symptoms may certainly be 
present without any ulcer. In the few cases in which a 
gastric ulcer is present in older children, the symptoms, if 
definite, should be as in adults — epigastric pain and vomit- 
ing. The follicular ulcer cannot be diagnosed, and has 
always been found accidentally upon the post-mortem 
table. 

Treatment. — The bleeding is often so quickly fatal that 
nothing is available ; but the directions to be given for 
cases of melaena neonatorum* will equally apply here. 

Tubercular Ulceration of the stomach is occasionally 
met with, but it has no symptoms apart from those of tabes 
mesenterica. 

Softening of the Stomach or gastro-malacia is a condi- 
tion which has received a great deal of attention, and some 
of the most distinguished writers upon the diseases of chil- 
dren have credited it with being a distinct disease, but to 
my mind with insufficient reason. Of symptoms it has 
none which are in any way characteristic, and the appear- 
ances found after death are identical with those of post- 
mortem solution. Whether this as well as other changes 
which are cadaveric in their nature may not at times com- 
mence during the last hours of life may perhaps be an open 

* Page 95. 



DISEASES OF THE INTESTINES. 93 

question, but that the change is, in all cases, essentially 
what has been described as post-mortem solution there is 
no doubt. 

Dr. Goodhart has twice found evidence of a gastric solu- 
tion of the lung which had gone on during the life of the 
patient. Into the appearances of the parts it is needless to 
enter further than to say that they showed a distinctly pecu- 
liar broncho-pneumonia, and that in each case there had 
been a moribund condition associated with vomiting for 
some days before death. Now it is obvious that such a con- 
dition has no right to the position of a disease, it would 
never have occurred had the circulation of the patient 
been at its proper tension. It was the result of an ebbing 
life, not a disease which caused death. So it is with the 
gastro-malacia of children. It is the result of exhausting 
disease of any kind, and is virtually, if not literally, a post- 
mortem change. 

3. DISEASES OF THE INTESTINES. 

Before entering upon the consideration of intestinal dis- 
orders proper, it may be well first to consider some of the 
appearances presented by the alvine evacuations. 

There is no need for more than a mention of the com- 
mon anxiety expressed by so many mothers at the black 
color of the motions when children are taking iron salts. 
Iron is so common a remedy for all sorts of ailments in 
childhood, that every student is familiar with the inky ap- 
pearance of the motion produced by it. But the passage 
of blood is sufficiently common to require special notice, 
and various undigested or partly digested substances pro- 
duce peculiar appearances which may well receive special 
attention. 

Blood may be passed unaltered, or resembling treacle or 
pitch (melaena). Fresh blood is a common constituent, and 



94 DISEASES OF CHILDREN. 

it comes from the lower part of the bowel, in association 
with the irritation set up by ascarides, with prolapse of the 
rectum, or with polypus. Occasionally it may be passed in 
quantity, and even in clots, when the child has been fed 
upon indigestible food. The following case is an example 
of this : — 

A child, aged seventeen months, had been fed upon meat 
and potatoes and arrowroot. Five days before she was 
brought to the hospital she began to pass blood, and after- 
ward some came away at every action of the bowels, some- 
times in clots. Some straining occurred with each action, 
and she turned very pale. Nothing abnormal was to be felt 
in the abdomen, nor was there any polypus or other cause 
for the bleeding to be felt per anum ; and it was therefore 
concluded that the diet was at fault. Careful feeding was 
ordered, and a mixture containing bicarbonate of potassium, 
fluid magnesia, and tr. of rhubarb and cinnamon water ; and 
the bleeding ceased. 

It also occasionally happens that a small ulcer in the 
colon or elsewhere in typhoid fever, or in children who are 
otherwise ill, comes across the line of a small artery, and 
leads to hemorrhage ; but the preexisting indications of 
disease would be, in such a case, sufficient to render a diag- 
nosis possible, the hemorrhage would have nothing in it to 
take it out of the category of a similar bleeding in adults 
under like circumstances, and the treatment would follow 
the same lines. 

Meloena neonatorum is a not very infrequent occurrence, 
and there has been considerable discussion as to the source 
of the blood. In the only case seen by Dr. Goodhart, a 
small oval ulcer had opened into an artery at the cardiac 
end of the greater curvature of the stomach. But this is 
perhaps an exceptional condition ; at any rate, the majority of 
cases have been supposed to be due to venous congestion. 



DISEASES OE THE INTESTINES. 95 

In typical cases, within a few hours of birth the infant 
either vomits blood or passes a quantity per anum, and 
sinks within a short period. The case alluded to occurred 
in the practice of Mr. W. Cock. The child was born 
naturally, and was to all appearance healthy. About 
twenty-four hours after birth it began to pass thick blood 
per anum, and vomited blood from the mouth, and it sank 
six hours afterward. It is a very serious affection, and in 
most cases fatal. Indeed, it hardly gives an opportunity 
for treatment; but should it do so, some cold alum whey 
should be given, and some castor-oil, which by acting upon 
the bowels may do something to relieve any local plethora 
which might exist. Dr. West narrates two cases of melaena 
in somewhat older children, in which the bleeding was per- 
haps due to some impoverished state of blood ; and it may 
be added that no one is exempt from ulcer of the stomach, 
though it is far less common in infancy and childhood than 
in later years. 

The spinach stool has usually been said to be due to 
altered blood; but grass-green evacuations are quite com- 
mon in acute and subacute diarrhoea in infants — so much 
so that there must be other sources than blood. More- 
over, the vomit of adults is often green, and then certainly 
composed of bile, and there is no reason to doubt that a 
green bile passing rapidly along the intestines under con- 
ditions of diarrhoea is an adequate explanation of some 
cases. M. Hayem also contends that a green color is pro- 
duced by a substance developed by a particular bacillus, 
and this he maintains is contagious. 

Oily matter is occasionally passed in quantity from the 
bowels ; the evacuation being, at the same time, very offen- 
sive. This condition is probably due to defective action 
of the liver, pancreas, and intestinal glands, under which 
the fatty matters of the food are not properly emulsified, 



g6 DISEASES OF CHILDREN. 

and, therefore, not absorbed. There is no experience at 
hand sufficiently large to warrant one in saying what 
is the best medicinal treatment for such cases ; but the 
symptom has disappeared under restricted diet, the use 
of sulphate of magnesium, sulphate of iron, and bicar- 
bonate of sodium. 

When, from any cause, it is necessary to feed children 
upon unusually large quantities of milk, the motions some- 
times contain a yellowish and greenish-thick fluid, not at all 
unlike thick pus, due to partially digested milk. In a case 
of empyema, it was so like pus that it led to the supposi- 
tion that the pleuritic abscess had opened into the colon - 
through the diaphragm. But there was no other reason to 
suppose that this was so, and microscopic examination 
showed the material to be fatty. The indication probably 
is that the absorption limit has been overstepped and that 
waste is going on. The milk should, therefore, be lessened 
in quantity. 

Mucus is also frequently found in the evacuations of 
children. This is met with in cases of acute diarrhoea, 
and also in the condition known as mucous disease. 

There are several disorders of the intestines which are 
dependent upon imperfections of diet, and in the management 
of which much depends upon the judicious regulation of 
the quantity and quality of the food. These are simple 
atrophy; flatulence; colic and constipation. 

Simple wasting or atrophy is due to insufficient or im- 
proper food. If the food be bad — that is indigestible — the 
wasting is generally associated with symptoms of intestinal 
disorder, which may be best treated under the head of diar- 
rhoea, colic, and so on. Naturally enough the two condi- 
tions, insufficiency and indigestibility, are commonly asso- 
ciated in practice. 

Nevertheless, it is well to remember that among the 



DISEASES OF THE INTESTINES. 97 

many infants who require dietetic treatment, the total 
number of cases due to simple starvation is not inconsider- 
able. The diagnosis must, for the most part, be arrived at 
from the absence of symptoms indicative of any local dis- 
ease. The infant does not get on, or gradually loses the 
plumpness it has gained, becomes pale and thin and is 
always crying. Still it fails to attract notice by any definite 
signs of illness ; on the contrary, it is not unusually bright 
looking and intelligent, it is easily attracted and pacified for 
the moment, doubtless solaced with the hope of the coming 
meal which is to bring freedom from its pangs. These 
children are pale, sharp featured, the fontanelle depressed, 
the arms and legs and buttocks thin, the muscles flabby, and 
the skin cool and moist. They are always crying, the cry 
being noisy and passionate, and in the best-marked instances 
alternates with vigorous sucking at anything within reach, 
sometimes at the thumbs till they are raw. The meals are 
taken ravenously, and as soon as they are finished, or in the 
intervals of sucking, crying is repeated. In very young in- 
fants, from the absence of that pleasurable stimulus which 
should be conveyed by suitable food, the child dozes at its 
meals. In the worst cases, when exhaustion is extreme, it 
may even be persistently drowsy. Besides the above-men- 
tioned symptom we find that the child takes little or no 
notice of what is going on about him, but from time to 
time moves his head restlessly on the pillow, and mutters 
low, fretful moans. This condition may proceed to stupor. 
There is general hyperesthesia, so that the least movement 
causes whimpering. The eyes become sunken, and the 
fontanelle depressed. The abdomen is soft and generally 
natural in shape. There is most frequently a tendency to 
diarrhcea. The pulse is compressible. The viscera must 
be carefully examined in every case, and should show no 
sign of disease. But inasmuch as even very young infants 



98 DISEASES OF CHILDREN. 

are not exempt from insidious complaints such as empyema, 
broncho-pneumonia, or endocarditis, all associated with 
wasting, the diagnosis cannot be reliable until a thorough 
examination has been made. To take one example out of 
many, a child of eight months old was brought to the Eve- 
lina Hospital, for wasting. It had been fed upon bread and 
milk since the age of eight weeks. No wonder it had 
always been thin and lately had got thinner ! The bowels 
acted regularly and there was nothing about the face to 
indicate local disease, and without examination it might 
readily have passed for a case of atrophy from bad feeding. 
It lay in its mother's lap in a passive condition, and the 
mother had in fact become concerned about it, because the 
wasting had now gone to that extent that sitting up seemed 
a trouble to it. An examination of the chest revealed the 
existence of extensive broncho-pneumonia, which had not 
even been suspected. The chest was dull over the base of 
the lung on both sides ; tubular breathing extended up to 
the spine of the scapula on the one side, associated with 
bronchophony, and on the other was audible in patches, 
with much bronchitic crepitation in the larger tubes. 

Treatment. — A careful attention to the rules laid down 
for dieting healthy infants will in most cases prove success- 
ful. Inasmuch as the child has usually been improperly 
fed, it is generally advisable to give a few doses of some 
mild aperient, and none is better than castor-oil. It may 
be given in doses of ten drops twice or three times a day in 
an emulsion, or a single large dose of half a drachm to a 
drachm may be administered. 

Insufficient food must of course be met by an increase 
in quantity, but caution is necessary in doing this. The 
stomach of an infant who has been persistently starved for 
some weeks, or even months, will not tolerate- an immediate 
return to the quantity of food which would be suitable for a 



DISEASES OF THE INTESTINES. 99 

child of the same age under natural conditions. The increase 
is to be made gradually ; if not, the stomach, which is an 
organ which in early life is most punctilious in resenting 
any sudden departure from its recognized custom, will cer- 
tainly relieve itself by vomiting. An infant which has been 
taking perhaps half a pint of milk in the twenty-four hours 
with bread, and so forth, may have half a pint of milk sub- 
stituted for the bread, and the pint is to be, day by day, 
slowly increased till the proper quantity (two to three pints) 
is reached. Nor is it uncommon for such children to re- 
quire an amount of dilution of the milk out of proportion to 
their age. Educated upon faulty principles as it has been, 
the stomach adheres to them with pertinacity, or becomes 
so irritable that even proper feeding does not seem to suit, 
and the child can only be saved by the most patient and 
attentive regulation of its diet. Use what care we mav, 
whenever a child has continuously wasted for some weeks, 
the prognosis must be doubtful until it has begun to mend 
under the treatment adopted. 

Such cases indeed, but for the objections, often insuper- 
able, which have already been alluded to, should always be 
wet-nursed. When this is not possible, cows' milk prepared 
in such a way as to be as nearly like human milk as may 
be is to be given ; failing this, some one of the other foods 
which have been mentioned in the previous chapter. For 
the worst cases still further departures may be requisite. 
Whey, with a tablespoonful of cream added to it, will suit 
some ; whey and barley-water, or barley-water and cream, 
others. Sometimes artificially digested milk, or peptonized 
milk as it is now called, may be necessary ; sometimes a 
little beef juice. Any one of these may, in one case or an- 
other, enable the child to turn the corner, and when this 
is effected, a more natural diet can be gradually resumed. 
Alcohol, in suitable doses, is also indicated. 



IOO DISEASES OF CHILDREN. 

Flatulence and Colic are among the most frequent 
digestive disorders in infancy. They are so commonly 
associated that it is unnecessary to discuss their separate 
symptoms. Flatulent colic is recognized in most cases by 
its relation to meals. Soon after food a child becomes rest- 
less, kicks its legs about, begins to grunt, and then perhaps 
utters a piercing, or sometimes a prolonged and harsh cry. 
At the same time its stomach is rigid, its face turns pale, 
and after a time eructations take place, and perhaps some 
vomiting of curds. As digestion proceeds the pain ceases. 

The physics of flatulence are not easy of elucidation, 
but the condition is associated either with poorness or defi- 
cient quantity of milk on the part of the mother — when it 
is reasonable to suppose that it is due to emptiness of the 
stomach — or with indigestible food. It is frequent where 
cows' milk is given, and in that case is due to the formation 
of firm curd in the stomach, and ceases as soon as this is 
disposed of either by vomiting or the process of digestion. 
If it persist, speaking generally, it indicates that the stom- 
ach is still empty, or that the meal remains undigested. It 
is often associated with, and aggravated by, irregularity of 
the bowels ; constipation being usual, with an occasional 
attack of diarrhoea. Where the bowels are constipated the 
motions are pale, lumpy, often very large and hard. They 
are evacuated with much straining, accompanied by a little 
blood, which comes from the lower end of the bowel, and is 
due to injury of the rectal mucous membrane resulting from 
the abnormal consistence and size of the motion and to the 
straining necessary for its evacuation. 

Some infants appear to be hyper-sensitive to the contact 
of food with the mucous membrane of the stomach and 
intestine, and, even though it be in all respects proper, flatu- 
lence and griping are excited. Others there are whose 
bowels are from the first sluggish and prone to constipa- 



DISEASES OF THE INTESTINES. IOI 

tion. It is by no means an uninteresting subject for study, 
how far such idiosyncrasies foreshadow the temperament 
of after-life — the nervous or phlegmatic, for example ; but 
apart from this, it is no more than might be expected 
that in the first few weeks or months of infant life — when 
the stomach and intestine are called upon to perform func- 
tions to which they have hitherto been unaccustomed, and 
when they have no more than the transmitted capacity for 
their performance to rely upon — that they should be per- 
formed less regularly and perfectly than afterward, when 
they have become stereotyped and easy by training. 

If this be the true way to regard the often recurring 
improprieties of function met with in infantile disorders of 
the digestive system, a rational mode of treatment recom- 
mends itself spontaneously. The details as applied to any 
particular case may require some skill in their adaptation, 
and may even fail ; but the principles upon which they 
must be based admit of the clearest insight. For ex- 
ample, when dependent upon the want of training, flatu- 
lence and colic are best treated by carminatives ; in such 
case, stomachic stimulants, or charmers away of flatulence, 
possess a perfectly rational basis of action which their title 
does not suggest. A stimulant applied to the stomach 
when it is already struggling with a meal which it knows 
not how to dispose of, is not unlikely to make matters 
worse ; unless it should provoke vomiting, which is by no 
means a desirable issue in such cases. The drugs which 
are successful in so many cases as to warrant the name of 
carminatives, are all impregnated with some volatile oil of 
strong flavor, and impart a sense of warmth to the nerve 
filaments to which they are applied. Afferent nerves, when 
employed in conducting any powerful impression, are for 
the most part so fully occupied as to be incapable of attend- 
ing to other weaker exciters, and the stronger stimulant 

9 



102 DISEASES OF CHILDREN. 

will at any time displace the weaker. In flatulent colic, if 
some dill, fennel, or cinnamon water be given, the atten- 
tion of the nerve filaments is attracted by its difTusibility 
and pungency, and diverted from the food. Time is thus 
allowed for the gastric juice to act and for digestion to pro- 
ceed. In due course the irritating matters are broken up 
and disposed of; and the pain ceases till the next meal. 
Any of the aromatic waters may be given, though perhaps 
the aqua anisi or aqua cari are most useful ; a tablespoon- 
ful or more is to be put into each bottle of food, or a simi- 
lar quantity — sweetened with a little powdered white sugar 
— may be given afterward. 

The flatulence of emptiness is due to the poorness of the 
milk — a condition to be ascertained by an examination of 
the mother's breasts — and may be remedied by feeding the 
infant during the day, and putting it to the breast only 
night and morning. If with this reduction there is still 
but a scanty breast-meal for the child, hand-rearing must 
be adopted. 

The flatulent colic of indigestible food may be prevented 
by further dilution of the milk ; by the addition of an alkali, 
such as lime-water or bicarbonate of sodium ; or by the 
addition of barley-water or gelatine. Those things which 
tend to thicken the food slightly are most successful, prob- 
ably, as Dr. Eustace Smith states, by preventing the forma- 
tion of large masses of curd. 

When the pain is very severe the colic may be relieved 
by warming the feet ; by a warm linseed-meal poultice to 
the abdomen ; by twenty or thirty drops of brandy in a 
little warm milk-and-water ; sometimes by a teaspoonful of 
aqua chloroformi. Where there is any suspicion of the 
retention of irritating material in the intestine, some castor- 
oil must be given. This may be prescribed in emulsion as 
follows : — 



DISEASES OF THE INTESTINES. IO3 

R. Ol. ricini, fgss 

01. amygdak'j exp., f 3 ij 

Sacchari, Jij 

Pulv. acacia:-, jij 

Aq. cinnam., q. s. ad f^iij. M. 

Sig. — One or two teaspoonfuls for a dose. 

If it be accompanied by griping, a minute dose of opium 
may be associated, as three drops of the tincture in a 
three-ounce mixture, a drachm to be given twice or three 
times a day to a child of nine months to a year old. If the 
collapse be severe, the bowels should be evacuated at once 
by an enema — the child being wrapped in blankets the 
while. In all cases of flatulent colic it is essential to see 
that the child is kept warm. It is not only necessary to 
encase the legs and abdomen in flannel, but to see that the 
wraps are retained in position. It often happens that a 
flannel binder is put upon the abdomen, and sewn on, as it is 
thought, securely. It quickly slips up, and the abdomen 
is left quite uncovered, as may easily be proved by putting 
the hand under the clothes of half a dozen babies consecu- 
tively. Again, the feet are covered by worsted socks, and 
these are allowed to get wet with urine ; so that while 
having the semblance of being cared for, appearances are 
belied by facts. The clothing of infants is adapted for the 
most part to the exigencies of urination, etc. They are so 
constantly wet, that anything elaborate in the way of cloth- 
ing for the loins and legs is less convenient than the time- 
honored napkin. Hence it comes that while the thorax is 
well clothed in four or five layers of raiment, the abdomen 
and legs are practically naked — save for such melancholy 
protection as is afforded them by an overhanging petticoat. 
But the lower part of the body requires as much care as 
the upper. It is as sensitive to chills and as liable as other 
parts to receive and promulgate harmful impressions. 



104 DISEASES OF CHILDREN. 

Therefore, when long clothes are discarded they should be 
replaced by a pair of flannel drawers, such as can be fixed 
to the wraps covering the chest, and will go outside the 
necessary napkins, being tied loosely either over or under 
the socks at the ankles. Dr. Lewis Marshall, of Notting- 
ham, has combated the objections to the usual underclothing 
of infants by a special knitted jersey, admirably adapted to 
its purpose, and which it may be hoped will in time displace 
the flannel hitherto in vogue.* 

Constipation may be due to malformation about the anus, 
more frequently to fissure, but most frequently, of course, 
of all, to something amiss either in the tonicity of the bowel, 
the material it contains, or both. It is with the last group 
of cases that we are here concerned. The faeces are almost 
always paler than normal, or even gray like those of jaun- 
dice. Constipation may prove troublesome even from birth, 
and Dr. Goodhart refers to several cases in which the bowels 
acted only every seven or eight days for some weeks. 
Some recommend that when this is the case the suckling 
should be treated through the mother. But this is a plan 
which is neither pleasant for her, nor very successful in 
overcoming the constipation. If it be desirable to treat the 
case so, a seidlitz powder may be given, or some Carlsbad 
salts, or two drachms of bitartrate of potassium maybe dis- 
solved in barley-water, flavored and sweetened, and taken as 
a drink during the day. For the infant castor-oil is as good 
a medicine as any for temporary constipation. In chronic 
cases a little fluid magnesia twice or three times a day 
answers the purpose, or five grains of the sulphate of 
magnesium dissolved in syrup of ginger and dill water : — 



* For full directions as to infants' clothing, see " Hygiene of the Nursery, 
2d Edition.— Starr. 



DISEASES OF THE INTESTINES. IO5 

1£. Magnesii sulph., ^ j to ij 

Tr. capsici, n\v 

Syr. zingib. . . f^SS 

Aq. anisi,' q. s. ad 13 iij. M. 

Sic;. — Teaspoonful three times daily. 

Manna may be given with the food, or dissolved in an 
aromatic : — 

]£ . Mannre opt. Jjij 

Synipi, : f ~j 

Aq. cari., q. s. ad f 5 ij. M. 

Sig. — Teaspoonful three times daily. 

A powder of two grains of rhubarb and three of soda 
may be administered ever)- night. 

Some of these remedies, however, have but a temporary 
effect, and may even, by their secondary action, increase the 
tendency to constipation. The following prescriptions are 
serviceable : — 

R . Mannae opt., 

Magnesii carl)., aa 3J 

Ext. sennas fid., f^iij 

Syr. zingiberis, f 3 j 

Aqua?, q. s. ad f£ iij- M. 

SlG. — Two teaspoonfuls once, twice, or three times daily, for a child of 
two years. 

Or, 

R . Resin, podophylli, gr. *4 

Spt. vini rect, tt\xv 

Syrupi, q. s. adfjj. M. 

SlG. — One teaspoonful for a dose. 

When a few months have passed over, or if the child be 
brought up by hand, better than all oral medication is the 
plan of attempting to modify the diet, or of exciting the 
lower bowel to expel its contents by enema or suppository 
of soap or glycerine. A teaspoonful of fine oatmeal may 
be added to the morning meal, or barley-water may be 
mixed with each meal. Friction should also be applied to 



106 DISEASES OF CHILDREN. 

the abdomen, morning and evening, either by hand alone 
or combined with an oily embrocation. 

The barley-water is given as in previous cases. The oat- 
meal should be given, a teaspoonful well rubbed up with a 
little cold milk till it is of the consistence of cream ; hot 
milk to the required amount for the meal is then to be 
added, and the whole boiled for a few minutes, when it is 
ready for use. As boiled milk is somewhat constipating, 
the editor prefers to prepare oatmeal as follows : Take a 
teaspoonful of finely ground Bethlehem oatmeal, add to 
two fluidounces of water, and heat without boiling but 
with stirring for five minutes, remove from fire, add the 
same quantity of milk, two teaspoonfuls of cream, and half 
a teaspoonful of sugar of milk. This preparation is suited 
for an infant six weeks old. If it be necessary to add an 
alkali, a grain or two of bicarbonate of sodium can be used, 
as being devoid of the constipating tendency often observed 
with lime-water. 

For an enema all that is necessary is to take two or three 
ounces of warm water and lather a little yellow or curd soap 
into it, and inject it by means of a caoutchouc bottle- 
syringe. A drachm or two of castor-oil may be added to 
the soap and water if necessary. An enema may be ad- 
ministered every morning, or even twice a day if necessary, 
and there is little objection to its daily use as long as may 
be requisite. It is never to be given unnecessarily, but if 
the bowels do not act spontaneously the action should be 
ensured by an enema, and this may be done without any 
fear of inducing such a habit as would require its perma- 
nent use. Glycerine enemata are to be highly recom- 
mended — one-half a teaspoonful with two teaspoonfuls of 
water is the proper dose for a child of six months. It is 
but seldom that the bowels fail to act properly when the 
diet becomes more varied. 



DISEASES OF THE INTESTINES. IO7 

Should the constipation be associated with much flatu- 
lence and pain, a teaspoonful of fluid magnesia may be 
given combined with a little spirit of nitric ether and sul- 
phate of magnesium : — 

ft. Spt. a-'theris nitrosi, f^j 

Magnesii sulphatis, 3J 

Olei cajuputi, mj 

Syrupi tolutanis, f 5J ij 

Liq. magnesii carl). (Br. P.), q. s. ad f 3 i j . M. 

SlG. — One teaspoonful two or three times daily. 

If associated with heartburn, which may be known by 
hiccough, which causes the child to cry or make faces, at 
the same time that it performs certain gustatory movements, 
bicarbonate cf sodium is to be given, and it may be com- 
bined with tincture of mix vomica, as recommended by Dr. 
Eustace Smith : — 

Be . Sodii bicarbonatis, 3 j 

Tr. nucis vomica:, \X\\] 

Tr. cardamomi comp., 

Syrupi, aa f SJ ij 

Aq. chloroformi (Br. P.), ^5 SS 

Aqua?, q. s. ad f]§ ij. M. 

Sig. — One teaspoonful every six hours. 

This combination is also useful when the bowels are per- 
sistently sluggish, on account of the nux vomica which it 
contains. A little glycerine may be added with advantage. 
The bicarbonate of sodium is also indicated when the eructa- 
tions are sour-smelling from fermentation going on in the 
stomach. It may be usefully combined with bismuth and 
carminatives : — 

K . Sodii bicarbonatis, gj 

Bismuthi subnitratis, % ss 

Pulv. tragacanth. comp. (Br. P.), £ss 

Syr. tolutanis, f 5 ss 

Aqua" cari, q. s. ad f^ij. M. 

SlG. — One teaspoonful three times daily. 



108 DISEASES OF CHILDREN. 

Other remedies may occasionally be found useful. Aloes 
powdered and dissolved in milk is recommended by some ; 
five or six grains of Socotrine aloes may be given three or 
four times a day till the bowels act; or it may be made into 
a syrup, a drachm of the aloes to an ounce and a half of 
syrup with some liquid extract of licorice ; or a small dose 
of euonymin (best administered in a powder with white 
sugar, gr. y^ of the drug) ; or a drop or two of the tincture 
of podophyllin or of the fluid extract of cascara sagrada ; 
but such drugs will not be required often if attention be 
paid to the causes of the constipation, if the diet be care- 
fully regulated, and the general hygiene of the nursery — 
warmth, bathing, cleanliness — be kept at the right standard. 

In children past the age of babyhood constipation is an 
occasional and somewhat troublesome affection. It is more 
common in girls than in boys. The subjects of it are usu- 
ally thin and wayward in temper, without anything definitely 
wrong; their appetites are capricious, the breath often offen- 
sive, and they are supposed to have worms. These are 
children who do no credit to good living, and who trouble 
the doctor because they are somewhat tardy in answering 
to his remedies, and because some of the symptoms may 
lead him to suspect the onset of the formation of tubercle. 
The abdomen in these cases is large and tumid, the disten- 
tion being sometimes remarkable. Dr. Goodhart has seen 
several cases where ascites was supposed to exist because 
of such distention and the existence of a percussion wave 
resembling that attending accumulations of fluid. In the 
large, pendulous abdomen of chronic constipation, we should 
be cautious in asserting the presence of liquid, the only 
reliable sign of the latter being an alteration of the level of 
resonance with changes in posture. Such* cases are, as Dr. 
Cheadle suggests, best treated with adequate doses of the 
sulphate of magnesium or sodium, combined with strych- 



DISEASES OF THE [NTESTJNES. IO9 

nia, belladonna and iron. Henoch mentions even more 
extreme cases in children of seven and nine years in whom 
the constipation gradually leads to extreme distention of 
the whole abdomen, with pain and tenderness, so as to 
simulate peritonitis. Dr. Goodhart makes the following 
statement in this connection : " I have myself seen one or 
two cases which may have been of this kind, but in which 
there has been visible peristaltic action and a dilated rectum. 
One boy, I remember, was much relieved by the use ofene- 
mata, and the daily evacuation thus insured, but when they 
were discontinued he was not permanently better, and I could 
not but suppose that the constipation had its origin and persist- 
ency in some organic disease which could not be unveiled." 
For constipation in older children, regular habits must be 
enforced. It is at least as necessary that a child should go 
to the closet regularly, as that she should do certain house- 
hold duties, or perfect herself in certain accomplishments 
with regularity. But this is a matter that many mothers 
never think of. In the next place, cases of this kind are 
not adapted for the exhibition of purgatives. Some gentle 
alkaline laxative may.be given for a day or two, and if it 
were not so nauseous to most palates, none is better than 
the old-fashioned rhubarb and soda. Hospital out-patients 
take this, and even like it, but other children very seldom 
do, and a dessert-spoonful to a tablespoonful of the liq. 
magnesii carbonatis is taken by them with less repugnance. 
The editor has found that rhubarb, while primarily a laxa- 
tive, has a secondary astringent, and therefore constipating 
effect. The following, in children who are old enough to 
swallow a pill, is most useful : — 

R • Ext. belladonna, gr. % 

Pil. aloes et myrrhae, gr. ix 

01. cari, git. ij. 

M. et ft. pil. No. vi. 
SlG. — One pill at bedtime for a child of six years. 
lO 



110 DISEASES OF CHILDREN. 

The advantage of this combination is that it is accumulative 
in its action, and that, in consequence, the dose can be 
gradually reduced. Cheadle's formula of twenty to forty 
grains each of the sulphate of soda and sulphate of mag- 
nesia is efficient. It should be combined with nux vomica, 
or that and belladonna, and be continued twice daily after 
food until the bowels act regularly. Some take Friedrich- 
shall very well ; others, the granular effervescing salts. 
There is no objection to the administration of a single 
purgative of more active nature if it be only to insure that 
the intestinal canal be cleared of all irritating contents. A 
grain of calomel, with six or eight grains of compound jalap 
or scammony powder, is efficient for such a purpose for a 
child of seven to ten years old ; or a quarter to half a 
Tamar Indien lozenge may be given instead, the remedy 
being more pleasantly administered in the lozenge form. 
Aloin and cascara sagrada may also be administered in 
tablet form. All active drugs are to be given with this one 
distinct object in view, and must not be resorted to repeat- 
edly. When all such preliminary difficulties are cleared 
away, the constipation is to be cured by plenty of exercise 
in the open air; by a diet of plain nutritious food, with 
green vegetables and fruit; by insisting upon the proper 
mastication of all food, and by drugs which act as hepatic 
stimulants and tonics ; strychnia may be given as a tonic 
to the bowels and arsenic and iron as blood restorers. 
Euonymin and podophyllin in small doses are useful mem- 
bers of the former class. 

R • Euonymin, gr. iss 

Sacch. alb., gr. xxx. 

M. et div. in chart. No. vi. 
Sig. — Once, twice or three times a day. 

R. Tr. podophyll. (B. P.), ^ss. 

Sig. — One or two drops on sugar once or twice a day. 



DISEASES OF THE INTESTINES. I I I 

R. Liq. sodii arseniatis, f^j 

Glycerinae, fjij 

Decoct, aloes comp. (B. P.), . . . . q. s. adf^iij. M. 
Sig. — One to two teaspoonfuls three times a day for a child of six to 
ten. 

R. Liq. strychnine (B. P.) mjcx 

Liq. ferri pernitratis (B. P.), f ^ j 

Acid, nitric, dil., f% ss 

Glycerince, . . f ,-j ss 

Aquae cari (B. P.), q. s, ad f,$iij. M. 

Sig. — Two teaspoonfuls three times a day at age of six years. 

R. Ex. belladonna;, gr. j 

Glycerina?, f^j 

Vini ferri amar., q. s. ad T^iij. M. 

Sig. — Teaspoonful three times a day at age of six years. 

Constipation, when it is unassociatcd with other symp- 
toms, is not a condition which does much harm, and it may- 
be remedied by patience and a little management. 

Constipation, when it is associated with sickness, always 
requires careful investigation, and the possibility of intus- 
susception or of brain disease or peritonitis should be 
remembered. 

Constipation, when it is obstinate from birth, demands an 
examination of the rectum. Narrowing of the canal from 
the presence of some partial septum or other congenital 
malformation, is rare, and for that reason is apt to be over- 
looked in its less extreme phases. Other forms of malfor- 
mation, such as internal stricture of some portion of the 
small intestine, and even hernia, occasionally exist, but such 
cases are very uncommon. 

Lastly, constipation in young children is by no means 
uncommonly associated with small fissures about the anus. 
The pain of defecation is so severe in these cases that the 
sphincter contracts tightly and prevents any successful ex- 
pulsive efforts. If there be an anal fissure, the bowels must 



112 DISEASES OF CHILDREN. 

be kept slightly relaxed, to obviate any stretching of the 
part, and the fissure should be treated locally by keeping 
the lower inch of the bowel and anus well greased with an 
ointment composed of equal parts of lead, zinc, and mercu- 
rial ointment, or it may be dusted with equal parts of calo- 
mel and oxide of zinc. Occasionally it may be necessary 
to paint it with nitrate of silver, and at times it is necessary 
to stretch it forcibly with the fingers, on the same principle 
as the surgeon finds it necessary in the adult to divide 
the superficial sphincter with the knife. This procedure 
the American editor has found most efficient, and as the 
operation is a trifling one, and so uniformly and quickly 
successful, it is to be highly recommended in all cases of 
fissure. 

Diarrhoea. — " When the alvine excretions are abnormally 
liquid, frequent and profuse, whether they consist of the 
residue of undigested or incompletely digested food ; of the 
product of the secretions of the intestines, the pancreas or 
the liver ; whether they contain blood or not, or the debris 
of the mucous membrane, we say that there is diarrhoea."* 
Dr. Goodhart writes : " Some writers have described many 
forms of diarrhoea, and would thus make the subject a com- 
plicated one for the student; but there is no corresponding 
morbid anatomy for the different kinds of looseness of 
bowels, and the results of treatment suggest a very simple 
division. Diarrhoea is the symptom of disordered or exces- 
sive function on the part of the neuro-muscular apparatus 
of the intestines, and any organ which depends for its action 
upon organic muscular fibre is liable to such functional de- 
rangements as may by their continuance become a con- 
firmed habit, and yet have no appreciable morbid anatomy. 
The uterus may persistently abort time after time from the 

* Trousseau, " Clinique Medicale," 1868, vol. in, p. 98. 



DISEASES OF THE INTESTINES. I I 3 

irritation of a syphilitic foetus, for example, and show in 

itself no reason for so doing. The stomach may repeatedly 
cast its contents in similar fashion, and in children, and less 
frequently in adults also, diarrhoea may continue for months, 
resisting all treatment without adequate cause in any struc- 
tural lesion. The student must not therefore conclude, as 
he is often inclined to do, that because the diarrhoea is 
chronic and intractable, it is due to ulceration of the 
bowel ; much less that not only is there ulceration, but 
that that ulceration is tubercular. 

The arrangement proposed as simple, and in accordance 
with practice, is into acute and chronic diarrhoea, and in 
limine this generalization may be made : — 

Looseness of bowels which has existed any length of 
time should be closely investigated, as it is pretty sure to 
prove troublesome to stop, and may indicate serious disease 
of the intestine and mesenteric glands. The diarrhoea, 
which comes on suddenly, and prevails to such an extent 
in the hot season of the year that it has received the name 
of summer diarrhoea, while not wanting special dangers, 
need give rise to no such anxieties, being often readily 
curable by simple means. 

Of late years summer diarrhoea has been thought to 
be an index of the sanitary condition of large towns, and 
to be due in larger measure to filth and putrefactive pro- 
cesses than, as had been previously thought, to simple 
atmospheric disturbances, the nervous activities of denti- 
tion, and so on ; and this view is probably correct. The 
very existence of large towns implies the presence of more 
or less material which possesses the power of originating 
putrefaction of all sorts'. ' Aggregation is necessarily more 
favorable to the transmission of septic material than isola- 
tion can be. The subjects of this complaint are all under 
five and most of them under two years of age, that is 



114 DISEASES OF CHILDREN. 

to say, they are in great measure milk-eaters, and milk is 
a fluid which is very sensitive to contamination.* It may 
therefore be very readily supposed that whatever tends to 
lessen the risk of this — and what more so than paying 
attention to the sanitary condition of a town ? — will by 
lessening the risk of decomposition to which milk is liable, 
just so much lessen the amount of summer diarrhoea. 

But the whole subject is not wholly embraced by this 
statement. There are some children, and some adults too, 
who are readily affected by alterations of barometric press- 
ure, electrical atmospheric disturbances, and so on. Loose- 
ness of bowels is noticed in such subjects on sudden fall or 
rise of the mercurial column ; sudden change from one 
extreme to the other of heat or cold, or in thundery 
weather. 

What such reactions may indicate etiologically ; how far, 
that is to say, they indicate changes in the food, and how 
far act immediately upon the system, it is impossible to 
say, and happily for the purposes of therapeutics, though 
th^ facts are worthy of recognition, the treatment is unaf- 
fected. Diarrhoea is supposed, and probably correctly so, 
to have "many other causes, such as chills, over-feeding, 

* I may remind the reader that all organic liquids, though under ordinary 
circumstances liable to decomposition, remain absolutely unchanged as long 
as they are protected from particulate contagion, and there is good evidence 
that the various kinds of fermentation and putrefaction are due to the intro- 
duction and growth of various kinds of bacteria. Of milk in particular I 
may quote from Sir Joseph Lister, whose researches in this domain are well 
known (" On Lactic Fermentation," Trans. Path. Soc. of Lond., vol. XXIX, p. 
435) : " I once met with a bacterium, but only once, that would not live in 
milk; for extremely numerous as the varieties of bacteria appear to be, almost 
all of them seem to thrive in that liquid." The outbreaks of such diseases as 
typhoid fever, scarlatina, diphtheria, and even of epidemic diarrhoea, which 
have of late years been traced to a milk source, must, according to present 
knowledge, be explained in this way, although the actual bacterium or germ 
has not as yet been demonstrated. — (Goodhart.) 



DISEASES OF THE INTESTINES. I I 5 

improper feeding, dentition, pyrexia of all sorts, rickets, 
and syphilis ; some of the reputed causes arc associated 
with certain signs which, as already stated, have justified 
to some the description of many varieties. It is, however, 
sufficient to say that in some cases of diarrhoea there is 
more or less fever, in others perhaps vomiting ; in others 
there are lumpy motions of undigested food ; a want of 
bile; an excess of bile; a rice-water discharge. In other 
cases the evacuations are of peculiar color, pink or green, 
some are peculiarly offensive. 

In one form or another during the summer months the 
out-patient room of any children's hospital is overrun with 
cases of diarrhoea, mostly infants of four or five months old 
and upward. They group themselves into three varieties, 
which, for want of better names, may be termed : a. Simple 
diarrhoea, b. Febrile diarrhoea, c. Cholera infantum. Ex- 
ceptions may perhaps be taken to such a nomenclatuie 
as this, because any one of the three varieties may be asso- 
ciated with fever, and the simple may run on to the febrile 
form, or even to cholera infantum ; and this is still more 
the case if one should attempt to base a differentiation upon 
the character of the stools. 

Thus the history of a case of cholera infantum is that 
after the passage of perhaps several semi-liquid brightly- 
colored stools, the bile suddenly disappears, and the evacu- 
ation becomes rice-watery. But take any milder cases — in 
some the bile-colored, semi-liquid material changes stool by 
stool into a brownish, offensive fluid, and then becomes col- 
orless ; in others it becomes watery, with a green sediment ; 
in others again the stool is colorless and almost odorless 
from the first. As regards the duration of the abnormal 
characters of the stools, there is the utmost variety. In 
some perhaps there will be one or two watery, colorless 
stools, and then bile will reappear ; in some, the natural 



Il6 DISEASES OF CHILDREN. 

color comes back fitfully; in some, the muddy water or 
green stool continues for days; in most, the full flux of bile is 
long in reappearing. No matter what the disease or the 
classification may be, if the latter be based upon symptoms 
and not upon distinct pathological conditions, it is likely to 
be technically faulty, although it may be none the less use- 
ful to work upon. So here : simple diarrhoea is not symp- 
tomatically febrile, although the body heat may sometimes 
be increased. Febrile diarrhoea, on the other hand, is asso- 
ciated with the aspect, the tongue, and the pulse of fever; 
and cholera infantum, while it will often show a higher 
pyrexia than either of the other varieties, has nevertheless 
a characteristic garb of its own. 

a. Simple Diarrhoea (? Muco-enteritis, Catarrhal Enter- 
itis). — The complaint varies much in severity. To take a 
common case ; the child has been vomiting and purged for 
some days with little apparent disturbance of its health. 
There is a certain amount of pallor, a little fretfulness and 
restlessness, and slight rise of temperature. It is usually 
thirsty, will drink any quantity of cold water, and milk is 
vomited undigested in curds, The mouth is somewhat dry, 
the tongue redder than natural, and its papillae are promi- 
nent. There may be some erythema about the buttocks, and 
the motions are usually liquid, green, and offensive. Some- 
times the evacuations are bright yellow; in others again 
pale. The majority of such cases are readily cured by sim- 
ple treatment, but it also happens sometimes that, the diar- 
rhoea having existed on and off for a week or two, the 
symptoms of cholera suddenly develop. 

The treatment embraces careful attention to the diet, the 
administration of a gentle laxative (preferably castor-oil), 
and the subsequent use of mild astringents. 

If the stools be yellow, homogeneous, and have a fecal 
odor, a good prescription is : — 



DISEASES OF THE INTESTINES. \\J 

$ . Syrupi rhei aromat., fsjij 

Bismuthi sobcarbonatis, oi to 7>' x ) 

Syrupi acacia.-, f.^j 

Mist, cretae, q. s. ad f^iij. M. 

SlG. — One teaspoonfal every two or three hours. 

When the stools arc green, acid, and numerous, alkalies 
with opium do well : — 

li . Tr. opii deod., ff\, v j 

Bismuth, subcarb., ^r. lxxij 

Syrupi acacix', f 5 ss 

Mist, cretae, q. s. ad f 5 iij. If. 

Sic. — One teaspoon ful every two or three hours. 

Good results, too, arc sometimes obtained in tedious ^ 
by minute doses of calomel with opium and chalk. It is n< >t 
advisable to continue these longer than one or two days. 

b. Febrile Diarrhoea (Kntero-colitis, Summer Diarrh 
— This is a common affection in American cities during the 
hot months. It chiefly affects children in their "second 
summer," and those belonging to the poor, who are 
doomed to pass the hot months in crowded, ill-ventilated 
and filthy localities of large cities. 

Anatomical Lesions. — There is hypenemia of the intestinal 
mucous membrane, commonly limited to the ileum and 
colon and most marked about the ileo-caecal valve and in 
the sigmoid flexure. The isolated glands are enlarged, 
appearing like grains of white sand scattered over the 
mucous surface, and the Peyer's patches are tumid, pro- 
jecting and punctated. The peritoneum over the inflamed 
glands show areas of arborescent injection, and the mes- 
enteric glands are moderately enlarged. Dr. Holt states 
that the inflammatory lesions found in the intestines are to 
be regarded as a consequence of the diarrhoea, rather than 
the cause. This view is favored by the most marked altera- 
tions being always found in the caecum and sigmoid flexure, 
just where the irritating substances are longest detained in 



IIS DISEASES OF CHILDREN. 

their passage. The stomach is either normal, or the seat 
of catarrh, the mucous membrane being thickened, softened 
and reddened. 

Should the disease assume a chronic form — the " chronic 
diarrhoea" of our author — the glands break down and 
superficial rounded ulcers are formed ; there may be, also, 
linear ulceration of the mucous membrane at the points of 
deepest congestion. 

Etiology '.—The main causal factors are : a. Residence in 
large cities ; especially in those quarters where, the streets 
being narrow and ill-kept, and the houses overfilled and 
dirty, there are accumulations of organic matter to be 
decomposed and contaminate the atmosphere with noxious 
gases and bacteria, b. High temperature, particularly when 
associated with a moist air. The disease, almost absent in 
winter, begins to be noticed about the middle of May, gradu- 
ally increases, to rage in epidemic profusion in July and 
August, and disappears with the cool weather of the latter 
part of September, c. Improper food. Babies hand-fed 
from birth and those who are weaned early suffer most. 
Impure and sour milk, farinaceous preparations in excess, 
" tastes " of table food and fruit are most potent in produc- 
ing an attack. The poisons produced from food, ptomaines, 
are important elements in the etiology. Brunton has stated 
that most of the alkaloids resulting from the decomposition 
of albumen cause diarrhoea, and many of the nervous symp- 
toms of summer diarrhoea maybe due to the effects of these 
alkaloids — a species of toxaemia occurring, especially when 
the discharges are suddenly arrested, spontaneously or 
through the influence of drugs. Though multitudes of 
bacteria are found in the discharges, the question of the 
existence of a special microbe is still sub judice. d. Age. 
The majority of cases occur between the ages of six and 
eighteen months, one-fourth as many from eighteen to 



DISEASES OF THE INTESTINES. I I9 

twenty-four months, and a smaller proportion between birth 
and the sixth month. After the second year attacks are 
much less common. 

Symptoms. — The actual attack is preceded by restlessr. 
disturbed sleep, partial anorexia, sour-smelling eructations, 
slight increase in the number and decrease in the consist- 
ency of the fecal evacuations, and heat of the palms of the 
hands and soles of the feet. 

In one or two days, vomiting and diarrhoea begin. The 
former is more or less obstinate, and the ejecta consist of 
sour, badly-digested food. The stools range from six to 
twenty or more in twenty-four hours, and vary greatly in 
character from time to time. They may be semi-solid, 
yellow, with a fecal odor; or liquid, green and acid; or 
contain mucus or blood; or, finally, be almost serous and 
very offensive. The act of defecation is preceded by pain, 
and there may be tenesmus and slight rectal prolapse; in 
the latter condition blood is most apt to appear in the 
stools. 

The tongue is dry, red at the tip and edges, with a light 
white coating in the centre, appetite is diminished, thirst 
increased, and the abdomen is distended and sometimes 
tender to pressure. The surface is hot and dry, the ther- 
mometer indicating a moderate pyrexia, continuous for the 
first three or four days, but afterward remittent. The pulse 
is feeble and runs up to 120 or even 140 per minute. The 
urine is scanty, high-colored and muddy, and passed at long 
intervals. 

Early in the course of the disease — after a single day if 
the diarrhoea be severe — the face becomes pale, the eyes are 
sunken, lustreless and surrounded by dark rings, the nasal 
lines of Jadelot appear, the fontanelle, if membranous, is 
depressed, the body wastes, the muscles grow flabby, the 
skin of the buttocks and inner surfaces of the thighs is 



120 DISEASES OF CHILDREN. 

reddened by the acid stools and concentrated urine, and 
there is excessive prostration. 

When death approaches the patient either becomes 
drowsy, apathetic and cold, or fretful, with incessant vomit- 
ing, dry burning skin, rolling of the head from side to side, 
and perhaps unilateral or partial convulsions. 

If there be a tendency to recovery, the vomiting stops, 
there is more appetite, the skin grows moister and cooler, 
the urinary excretion is reestablished and the languor and 
apathy diminish. 

Diagnosis. — There is little difficulty in distinguishing 
entero-colitis. The fever, the vomiting, the number and 
appearance of the stools, the age, season and locality of 
occurrence, and the almost epidemic prevalence of the dis- 
ease are characteristic. 

Prognosis. — While a large proportion of cases recover 
under proper treatment, the outlook is always grave, and 
particularly so in the children of the poor, with whom it is 
impossible to practice the most efficient means of cure, 
namely, removal to the fresh air of the country or sea- 
shore. Relapses are apt to occur, and the disease is liable 
to become chronic, when it is very difficult to manage. An 
attack may prove fatal in four or five days; it may, however, 
be protracted for two weeks, the last is the usual duration 
of severe cases ending favorably. 

Treatment. — People who have not the means to take their 
families to a place of safety in the country or at the sea- 
shore for the summer months, may yet do much in the way 
of prevention by keeping their children, during the day, in 
the fresh air of public squares and parks, by bathing, by 
proper and clean clothing, good food, and attention to the 
cleanliness of beds and sleeping rooms. Clean streets are 
apparently too much to expect in the present state of our 
municipal governments, but there is no question that any 



DISEASES OF THE INTESTINES. 121 

improvement in this respect would lessen the frequency 
and mortality of summer diarrhoea. 

When an attack occurs the patient must, if possible, be 
sent at once from the city, the resort selected being near at 
hand, lest the journey be too fatiguing, but such as to afford 
a decided change of air. The effect of such a change is 
rapid and almost magical ; it is necessary, though, to make 
a long stay, since if the child be brought back to town in 
hot weather, a relapse is almost certain to occur. If the 
parents be too poor to afford this, they must keep their 
child out of doors in the cool of the morning and evening, 
or spend the day with it in a public park, or still better 
take it for a short excursion in a river steamboat. The 
heat of the day should be passed in as cool a spot as can 
be obtained. It is well to let the child rest on a cool clean 
bed, and to forbid its being constantly nursed on a hot lap 
or shoulder. 

The clothing must be as thin as possible provided always 
that woolen is worn next the skin. Several times a day in 
the early stages of the attack, the whole surface of the body 
ought to be sponged with water at 8o° Fall, and carefully 
dried with gentle friction ; after prostration has set in, full 
warm baths are to be employed. 

In ordering the diet, quantity as well as quality must be 
definitely stated, for the increased thirst causes much more 
liquid food to be taken than can be digested. It is better 
to meet this demand by bits of cracked ice and moderate 
quantities of iced filtered water, and to proportion the 
amount of food to the enfeebled digestive powers. 

This may be readily done with nursing babies by restrict- 
ing the intervals of feeding to two or three hours, according 
to the age, and by reducing somewhat the duration of each 
sucking. 

With hand-fed children it is still easier to fix the quantity; 



122 DISEASES OF CHILDREN. 

as to quality, good sound cows' milk must form the basis 
of every food. The following is a good preparation for a 
child of twelve months : — 

Milk, six tablespoonfuls. 

Cream, one tablespoon ful. 

Lime-water, five tablespoonfuls. 

Sugar of milk, one teaspoonful. 

Mix in a clean tin cup, pour into a clean bottle, adjust tip, and warm by 
plunging into hot water. 

Should it be impossible for the child to retain this quan- 
tity, one-half, or even one-fourth of it only may be given. 

It is always worth the trouble to see that the infant's milk 
is received and kept in a perfectly clean and special vessel ; 
that the bottles and tips (no tubular arrangement should 
ever be used) are also perfectly clean, and that each meal is 
prepared separately at the time of serving. In very hot 
weather, and when ice is scarce, it is a good plan to boil the 
whole day's supply of milk, when it comes in the morning, 
to keep it from souring, but under no circumstances should 
the meals for the day be mixed en masse. 

If vomiting be present, all food must be stopped for from 
twelve to twenty-four hours, and the thirst quenched by 
thin barley-gruel or mineral waters, — cold, and in small 
quantities. If the child be at the breast, as soon as vomit- 
ing is checked, it can gradually be brought back to its ac- 
customed diet, care being taken that too much food be not 
taken. In bottle-fed children under two years, it is better 
to withhold milk entirely; wine-whey, chicken and mutton 
broth, Mellin's food with barley-gruel, the juice expressed 
from rare beefsteak or roast beef, and sometimes raw-scraped 
beef, should constitute the " no-milk diet." 

The indications for medical treatment may be grouped 
under four heads: I. To clear out the bowels; 2. To stop 
decomposition ; 3. To restore healthy action in the alimen- 
tary tract; 4. To treat the consecutive lesions. 



DISEASES OF THE INTESTINES. I 23 

I. The bowels should be emptied as completely as pos- 
sible, as the first step in the treatment, and for precisely the 
same reasons that the surgeon cleanses a wound thoroughly 
before applying antiseptic dressing. This rule holds good 
not only where there is a history of antecedent constipation, 
or the evidence of the presence of indigestible food in the 
alimentary tract, but in every case in which there are altered 
secretions undergoing putrefactive changes. The only in- 
stances in which the process of cleansing should not be 
undertaken, because unnecessary, are those where, after 
two or three fecal or semi-fecal evacuations, the discharges 
consist of almost pure serum, large in amount, alkaline in 
reaction, and odorless. 

To sweep out the intestinal canal nothing compares in 
efficacy with castor-oil. Should the stomach be very irritable, 
however, it will be necessary to substitute enemata. These 
should consist of pure water at a temperature of 65 Fan., 
and to be efficient must be copious enough to reach the 
caecal valve, — about one pint in a child of six months, and 
two pints in one of two years. The injection must be given 
slowly, with a fountain syringe, the abdomen meanwhile 
being gently manipulated. 

Many mild cases can be cured, if taken at the start, by 
castor-oil and a strict diet alone. 

2 and 3. To stop decomposition and restore a healthy 
action in the intestines, the administration of antiseptics and 
attention to diet are necessary. 

Antiseptics must be given in small doses lest the stom- 
ach reject them, and frequently to maintain a continuous 
action. The best are calomel, salicylate of sodium and 
naphthalin. 

Calomel may be prescribed in the following combina- 
tion : — 



124 DISEASES OF CHILDREN. 

R. Hydrargyri chloridi mit., g r - K 

Bismuthi subcarbonatis, gr. xxxvj 

Pulv. aromatici, gr. vj. 

M. et ft. chart. No. xii. 

Sig. — One powder every two hours. 

Salicylate of sodium is prescribed in doses of from one to 
three grains every two hours, according to the age, from 
three months to three years. An aqueous solution is taste- 
less, and can readily be given in the food or drink ; it has 
a tendency to check rather than occasion vomiting. It may 
also be substituted for the calomel in the above prescription. 

Naphthalin, although possessing a strong odor, is not 
disagreeable to the taste. On account of its insolubility, it 
is best administered rubbed up with some inert powder 
like sugar .of milk. The doses should be larger than those 
of the salicylate of sodium, — one to five grains according 
to the age. 

Resorcin and bichloride of mercury are also useful anti- 
septics. Resorcin is bitter, and though freely soluble in 
water, not easily administered ; the dose is one-half a grain 
to two grains. The bichloride is given in doses of t |-q 
to y^-Q of a grain, but even in these minute quantities fre- 
quently causes vomiting. 

Counter-irritation by mustard plasters to the belly is use- 
ful. Stimulants are required when prostration sets in, and 
must be given in doses and at intervals adapted to the de- 
mands of the case. 

Applications of oxide of zinc ointment, with cleanliness, 
cure the intertrigo of the buttocks and thighs most quickly, 
or, at least, keep it in check until the cause is removed. 

4. The essential consecutive lesions are in the colon, and 
consist practically of a follicular colitis. When the condi- 
tion of ulceration is reached, astringents by the mouth are 
useless, with the possible exception of bismuth. 



DISEASES OF THE INTESTINES. 125 

Three things are valuable : — 

First. As careful attention to the diet as during the acute 
stages, and in recent cases. Deviation from dietetic rules 
is the most frequent cause of relapse. 

Second. The continuance of antiseptics to check intesti- 
nal decomposition, and hence stop irritation. 

Third. The whole large intestine should be washed out 
once every day, either with pure water at 65 ° Fah., or 
with weak antiseptic or astringent solutions. Of the former 
the best are benzoate or salicylate of sodium ; of the latter, 
nitrate of silver or tannic acid. 

Attention to diet and hygiene is not to be relaxed when 
convalescence is established, and after the measures calcu- 
lated to check diarrhoea are unnecessary, digestants, as wine 
of pepsin, and tonics, as the ferrated elixir of cinchona, are 
still required to restore the health. 

c. Cholera Infantum is the analogue of cholera morbus 
in the adult. 

Anatomical Lesions. — In typical cases, the gastro-intestinal 
mucous membrane is congested, thickened, and softened, 
and the glands, both solitary and agminated, are enlarged. 
When the patient survives the choleraic stage, and dies sub- 
sequently of a more protracted diarrhoea, there is more in- 
tense inflammation, with ulceration of the intestinal mucous 
surface. In addition, the sympathetic nervous system is so 
involved as to allow the transudation of serum from the 
blood vessels into the intestines, and lead to alterations in 
the functions of the heart, lungs and kidneys. 

Etiology. — Infants from six to twelve months are the most 
ready subjects, but it may occur at any age up to two years. 
In other respects, the causation is identical with that of 
entero-colitis. 

Symptoms. — The onset of cholera infantum is sudden, 
whether it occur in the midst of health or during the course 
1 1 



126 DISEASES OF CHILDREN. 

of an ordinary diarrhoea. The first symptom is the expul- 
sion of very large watery stools ; these may be so serous as 
to soak away into the napkins without leaving any more 
stain than healthy urine, or they may contain yellow or 
green flocculi and little masses of mucus ; or, again, they 
may be composed of dirty-brown liquid. In the first two 
instances they are odorless, in the last they have a peculiar 
musty, putrid smell, which clings to the body and clothing 
of the patient. The number of evacuations varies from ten 
to thirty in twenty-four hours. 

Soon the stomach becomes intensely irritable ; everything 
is vomited almost as soon as swallowed, and there is severe 
retching. . The appetite is lost, there is intense thirst, the 
tongue is dry, pasty, and protruding, and the abdomen is 
flaccid. There is great restlessness ; the temperature runs 
up to 105 ° or even 108 , the pulse is small, and counts from 
130 to 150 per minute, the breathing is irregular, and the 
urine almost suppressed. After a few hours the infant 
seems to have melted into a mere shadow of himself; his 
face is pale and pinched, his eyes and cheeks sunken, and 
his eyelids and lips parted from muscular relaxation. The 
fat of the body melts away, the muscles grow soft, and the 
skin, dry and cadaverous in color, hangs in loose inelastic 
folds. Next, there is rapid collapse, with cold extremities 
and breath ; thready, uncountable pulse, unequal respira- 
tion, drowsiness, apathy, and totally suppressed urine. 

As death draws near, the vomiting stops, the skin is 
clammy, the face set, and the patient sinks into a condition 
of semi-coma. The end comes quietly, or is preceded by 
slight convulsive movements. 

The attack may prove fatal in from one to four days, or 
the type may change, and death occur later from secondary 
entero-colitis ; sometimes recovery takes place. 

Diagnosis. — The character of the stools, the extreme irri- 



DISEASES OF THE INTESTINES. 127 

tability of the stomach, intense thirst, high temperature, 
disturbed respiratory rhythm, and rapid emaciation and col- 
lapse, are distinctive features. There is a certain resem- 
blance between this disease and sunstroke, but the two 
conditions have little in common beyond the fact that they 
both occur in hot weather. 

The prognosis is very unfavorable. Early removal to the 
country or sea-side offers the best chance for recovery. 
Otherwise daily airings and steamboat excursions must be 
resorted to. 

Treatment. — To replace the great waste, food and water 
must be given in such quantities as can be retained — even 
a teaspoonful at a time — and at intervals corresponding in 
frequency with the smallness of the amount. The quality 
of the food must be the same as in entero-colitis. 

To check the purging, astringents and opium are neces- 
sary. Sulphuric acid is very efficient : — 

1£. Acid, sulph. aromat., n\xxiv 

Liq. morphke sulph., f^j 

Elix. curagoce, f.^ij 

Aquae, q. s. ad f 5 iij. M. 

Sig. — One teaspoonful every three hours, for a child one year old. 

At the same time, an enema containing two or three drops 
of tincture of opium should be administered every three 
hours. If vomiting be not very severe, small doses of 
castor-oil may still be given. They will speed onward any 
noxious matters in the intestines without increasing the 
state of collapse. If the vomiting be incessant, half-grain 
doses of hydrargyrum c. creta or one-sixth-grain doses of 
calomel should be given every hour for three or four doses. 
Henoch speaks highly of hydrochloric acid in small doses, 
and also of creasote. Dr. Goodhart writes, "I now give 
salicylate of soda on the antiseptic hypothesis, as in the 
milder cases, but the disease is so severe, and the general 



128 DISEASES OF CHILDREN. 

disturbance of function so quick and so crushing, that 
under any known method it still retains a sad fatality." 
Another remedy which promises well is a tincture of coca, 
made by adding one part of leaves and five parts of abso- 
lute alcohol. From five to twenty drops are given, accord- 
ing to age (in every case under two years), and improvement 
generally sets in when fifty to one hundred drops have been 
taken. Another method of treatment has of late been ad- 
vocated for this and kindred intestinal diseases by Monti 
and other foreign observers — viz., that of " intestinal irriga- 
tion." Copious enemata (Oj to Oiij) of warm, tepid, or cold 
water are allowed to flow into the bowel under a low pres- 
sure from some handy reservoir, or are carefully introduced 
by an "Alpha syringe," the child lying on its back with its 
buttocks raised. If any straining occurs the injection is to 
be stopped. Mustard draughts should be applied to the ab- 
domen three times a day, or a flax-seed poultice warmed with 
a dash of mustard may be worn constantly, and the body 
must be sponged several times daily with water at a tem- 
perature of 95 . 

The patient should lie upon a bed, not in the lap ; perfect 
cleanliness of person, diapers and clothing is essential, and 
the sick-room must "be as large, cool and airy as can be 
commanded. 

Stimulants are necessary from the first. Five or ten 
drops of whiskey in a teaspoonful of lime-water may be 
given every two hours in the beginning, and increased as 
circumstances demand. Carbonate of ammonium may be 
combined, if the stomach permits, in bad cases. 

In collapse, the temperature must be kept up by hot 
flannel wraps, and hot-water bottles, and quiet in a hori- 
zontal position maintained. In this stage opium is to be 
used with caution, on account of its tendency to increase 
the stupor. A warm bath, and sometimes a mustard bath, 



DISEASES OF THE INTESTINES. 1 29 

should be given at once ; if the latter, about a tablespoonful 
of mustard to the gallon of water is used, and the child is 
kept in it till the nurse's arms tingle. It is then to be 
wrapped in blankets and kept very warm in the nurse's 
arms, or by hot bottles. 

In the fortunate favorable cases, secondary diarrhoea is 
to be treated carefully, and the general strength built up by 
gcod, digestible food, tonics and fresh air. 

Chronic Diarrhoea is very generally insidious in its 
origin. It often happens that the child is not brought for 
treatment until months after its commencement, and not 
till emaciation has made some progress. In reply to ques- 
tions, we are told that the bowels have always been loose — 
perhaps what began as an acute diarrhoea has become per- 
petual. Sometimes the attack has been the outcome of one 
of the exanthemata ; but however this may be, the child is 
brought because "as soon as any food is taken it goes 
through it," or for some imaginary enlargement of stomach, 
these being indications to the mother of "consumption of 
the bowels." It is but seldom, however, that this popular 
diagnosis is correct; and in at least nine cases out of every 
ten, consumption of the bowels means no more than a dis- 
order attendant upon improper feeding. 

Causes. — Chronic diarrhoea occurs for the most part in 
the ill-kept children of the poor of large towns ; in infants 
whose mothers are out at work all day long, and who are 
consequently fed on anything on a week-day, and probably, 
as a treat on Sundays, on a little of everything that the 
parents eat; it is found in the ill-washed with a skin choked 
by perspiration, dirt, and urine ; in the ill-clothed, with a 
surface repeatedly exposed and chilled — in all, in fact, who 
breathe bad air and are fed on bad food, and live under 
conditions hygienically faulty. Entero-colitis is also the 
cause of a certain proportion of cases of chronic diarrhoea 



I30 DISEASES OF CHILDREN. 

occurring in children from six to eighteen months old. In 
the children of the well-to-do, it usually results from im- 
proper feeding — not necessarily from food intrinsically bad, 
but rather from such which is ill adapted to the particular 
case. In many of the children in this class of society, the 
greatest care and forethought have been exercised ; still, 
there is something wrong in the food or in its method of 
administration. Chronic diarrhcea is also specially frequent 
in rickety and syphilitic children, and is also liable to begin 
in any who may be recovering from measles, whooping- 
cough or other debilitating disease. 

Symptoms. — The early history of cases of chronic diar- 
rhcea can but seldom be obtained from that class of society 
which furnishes the most abundant examples ; but from 
such children as have been under careful observation, it 
would appear that an acute attack of diarrhcea, acute dis- 
ease of one kind or another, or exposure to cold, are its 
usual precursors. There are many children, moreover, who 
are voracious from birth, who take their food with great 
rapidity, take more than is requisite, and who show symp- 
toms of indigestion and suffer pain afterward. Any of these 
conditions will lead to diarrhcea. The motions are at first 
abundant without being very abnormal. Very gradually 
they lose their color and consistency, the child at the same 
time losing its plumpness, and dwindling. The motions 
may at first be pultaceous and abundant, lumpy, with a 
quantity of mucus, or grumous and more like pus ; but in 
the late stages they become more and more frequent, 
amounting sometimes to twenty or thirty in the twenty- 
four hours ; more liquid ; more offensive ; and the color 
changes to reddish or to a dirty-brown water containing 
green particles " like chopped spinach," an apt comparison; 
this appearance is considered to be altered blood. The 
child meanwhile slowly wastes. For a long time, by a 



DISEASES OF THE INTESTINES. I 3 I 

negative rather than a positive process, the infant grows 
older but not larger. For long it is supposed to be rather 
bad-tempered than ill, for in the interval of the abdominal 
pains it may be bright and cheerful ; but by-and-by the 
emaciation cannot be overlooked — it becomes continuous, 
till in extreme cases only a living skeleton remains. The 
skin is brown and dry, hanging in folds upon the body and 
wrinkling the brow ; the buttocks become covered with an 
eczematous rash; the face is pinched and monkey-like; the 
cry, a hardly audible whine ; the tongue red and dry, rasp- 
like from the prominences of the papillae, and covered with 
thrush, and the abdomen, moderately distended by flatus, 
shows the intestinal coils visible through the thinned 
parietes, and the peristaltic action clearly discernible. Visi- 
ble peristalsis has not the same signification in children 
that so often attaches to it in adults. It may mean the exces- 
sive activity of the muscular coat of the bowel, but not that 
the muscular coat is hypertrophied ; it may be seen in many 
an emaciated child without any intestinal obstruction being 
present. If the diarrhoea be not arrested by treatment, the 
child gradually becomes more feeble, and sinks into a semi- 
comatose state. The temperature falls below normal ; the 
feet and hands are cold and cedematous ; and it either suc- 
cumbs to gradual exhaustion, or else some complication 
occurs — perhaps convulsions, perhaps broncho-pneumonia 
or pleurisy. The child is, however, often in so feeble a 
condition before the final event that such things create few 
if any fresh symptoms, and they are liable to pass unrecog- 
nized, until a post-mortem examination reveals them. Be- 
sides these, there is a liability to eczema, impetigo and 
ecthyma, and even gangrene of parts of the surface has 
been recorded. Such is the history of chronic diarrhoea in 
infants — an affection that may last from three or four weeks 
to as many months, or even longer. In older children — 



132 DISEASES OF CHILDREN. 

that is to say, from two years upward — it is found under 
three conditions of somewhat different import: 1st. As a 
state of irregularity of bowels rather than diarrhoea, the 
motions being often loose, but not unfrequently confined 
and lumpy. The diarrhceal stool is bulky, loosely pulta- 
ceous, dark-brown in color, and offensive. This is due to 
want of regularity in diet, and in certain cases where undi- 
gested food appears in the evacuations, has received the 
name of lienteric diarrhoea. This form is often associated 
with thread worms. It is attended also with a certain flab- 
biness of muscle and fat, but hardly ever with any serious 
wasting. 2d. There may be much wasting and abdominal 
discomfort, the abdomen being a little full and the motions 
muddy and offensive; in which case it is due to ulceration 
of the intestines and tabes mesenterica. Tubercular ulcer- 
ation, a lesion which frequently precedes inflammation and 
caseation of the mesenteric glands or tabes mesenterica, 
occurs mostly in children over three or four years of age, 
especially when these are subjects of the tuberculous or 
scrofulous diathesis. The seat of the disease is the ileum, 
the parts affected Peyer's patches and the solitary follicles. 
The ulcers are circular or oval with uneven, ragged edges 
in which careful examination reveals the presence of 
miliary nodules. They are more numerous in the neigh- 
borhood of the ileo-caecal valve, over which region there 
is tenderness on pressure, with a certain amount of tension 
of the parietes. The stools are composed of dirty-brown 
fluid with a deposit of flaky matter, small black clots of 
blood, pus and mucus, and are exceedingly offensive. 
The temperature is usually elevated in the evening, and 
should the ulceration be marked the mesenteric glands 
are apt to be enlarged. 3d. There may be little wasting, 
but more pain — the griping coming on almost as soon as 
any food is taken into the stomach, and the evacuations 



DISEASES OF THE INTESTINES. 1 33 

consisting of undigested food and mucus — a condition 
which appears to be primarily associated with some disorder 
of innervation (Diarrhee nerveuse of Trousseau), although 
excited immediately by the contact of food with the gastro- 
intestinal mucous membrane. This variety, the true Lien- 
teric diarrhoea, is met with in children from three to nine years 
of age, and is due to an unnatural briskness of the peri- 
staltic action, on account of which whatever food is taken 
is at once hurried through the alimentary canal, with a 
rapidity that allows of but slight digestive change. The 
stools contain little fecal matter, and are composed of almost 
unaltered food so mixed with mucus as to present a slimy 
appearance. They number three or four a day ; the first 
occurs in the morning after rising, the others immedi- 
ately after or even during a meal. Each motion is preceded 
by griping pain, and the call is most urgent, so much so 
that the child with difficult}- waits for the chamber or 
reaches the closet. The tongue is red at the tip and edges, 
lightly coated or clean over the dorsum. There are fre- 
quent griping abdominal pains with unproductive desires 
to defecate. Wasting and other evidences of failing health 
may or may not be present, and special inquiry is often 
necessary to discover the abnormal condition of the bowels, 
which by many parents are merely considered to be " nicely 
opened." 

Prolapse of the rectum is liable to occur in any case of 
chronic diarrhoea, but it is more common in children of two 
to six years than in infants. 

Morbid Anatomy. — The coats of the stomach and intes- 
tines are pale and thin, having suffered from the general 
atrophy, while the mucous* membrane of the lower part of 
the small intestine and of the colon is covered with black 
points, giving a cut-beard appearance which is due to altered 
blood pigment deposited round minute ulcerations of the 
12 



134 DISEASES OF CHILDREN. 

solitary glands and follicles. There may be in addition 
more or less superficial erosion of the mucous membrane, a 
streaky appearance from irregular turgescence of the capil- 
lary plexuses, with swellings of parts of the Peyer's patches, 
and, lastly, some cases prove to be overlooked examples of 
tabes mesenterica, with their thick-edged ulcers infiltrated 
with yellow material, and perhaps with distinct tubercles on 
the peritoneal aspect. It sometimes happens that a chronic 
catarrh may end in a more acute process. Thus it is that 
occasionally the unsuspected presence of acute enteritis is 
revealed after death. Bronchitis, broncho-pneumonia, or 
atelectasis are the more common affections found in con- 
junction with the intestinal lesions. The more or less 
comatose condition which so often comes on before death 
has been occasionally found to be due to thrombosis of the 
cerebral sinuses ; but this is a rare occurrence, and the 
symptoms are probably more often due to the slowing of 
the circulation and the feeble nutrition which ensues, or, 
possibly, as Parrot has suggested, to toxaemia (" Clinique 
des Nouveaux-nes "). 

Diagnosis. — It is desirable, if possible, to come to a con- 
clusion whether the diarrhcea be due to tubercular ulceration 
or not. The existence of small follicular ulcers cannot be 
diagnosed with any certainty, but the larger tubercular or 
scrofulous ulcers may be suspected in any child over two 
years in whom the diarrhcea is obstinate and there is much 
wasting. Of late years it has been the custom to teach that 
tubercle is a much commoner disease in infants than had 
been thought, and so, no doubt, it is ; but none the less it 
remains true that of all the cases of chronic diarrhcea met 
with in children, but few are tubercular under eighteen 
months. After two years the question of tubercle must be 
carefully considered. Much pain after taking food, associ- 
ated with a persistently brown watery offensive motion, is 



DISEASES OF THE INTESTINES. 135 

in favor of ulceration, and so also, with other symptoms, is 
any unusual excess of borborygmi in the intestine. Tuber- 
cular ulceration of the intestine has so much tendency to 
mat together the coils of intestine, and thus hamper their 
action, that some functional disturbance of this kind may 
certainly be expected. These points, and a careful observa- 
tion of the temperature, will generally suffice. A polypus 
in the rectum leads to a discharge of blood and mucus, 
which is sometimes characterized as a diarrhoea by the 
mother. An examination of the rectum settles the diag- 
nosis. 

Prognosis. — This must depend upon the result of treat- 
ment. If the diarrhoea lessens and the motions become 
more consistent, then a favorable termination may be hoped 
for. The older the child the better the chances. Much 
dryness of the tongue, with redness and enlargement of 
the papillae, accompanied by thrush; and any oedema of the 
feet and ankles ; are of the worst augury. 

Treatment. — To take the case of older children first, and 
excluding the possibility of tabes mesenterica, the diarrhoea 
which is due to irregularity of diet must be counteracted by 
paying attention to what has before been neglected. Chil- 
dren thus affected must be strictly treated, but they require 
some slight preliminary purgation to clear away indigestible 
and improper material from the intestinal canal. For this 
purpose rhubarb, calomel or aloes and myrrh are service- 
able, and readily administered. A teaspoonful to a table- 
spoonful of fluid magnesia may be given, if preferred, twice 
or three times in the day ; and for a more active aperient a 
small teaspoonful of licorice powder or a piece of a Tamar 
Indien lozenge may be given. Subsequently a little sulphate 
of magnesium may be combined with sulphate of iron, as 
such children are often anaemic, and require iron. A good 
prescription for the latter is : — 



I36 DISEASES OF CHILDREN. 

R . Fern sulphatis, gr, viij 

Magnesii sulphatis, gj 

Acid, sulphurici dil., fjjij 

Syr. zingiberis, f-f ss 

Aq. cari, q.s. adf^iv, M. ' 

Sig. — Two teaspoon r uls in water, three times daily, for a child of ten 
years. 

In the prolapsus ani, that is often present in such cases, 
it is rarely necessary to do more than support the parts by 
strapping the buttocks tightly together by a broad band of 
strapping encircling the hips round the great trochanters ; 
and, in the worst cases, giving an enema of sulphate of iron 
and cold water, a drachm to the half-pint, and a third part 
to be used at a time every morning, or morning and evening, 
for a few days. More severe measures are sometimes spoken 
of, but the circumstances under which they can be called for 
must be very exceptional. For the " nervous diarrhoea " 
nothing acts so well as small doses of Dover's powder. It is a 
disease particularly of children five to ten years old. Two, 
two and a half, or three grains may be given three times a day 
in a little milk, and an hour or so before meals. A little 
fluid extract of opium may be given in fluid magnesia, with 
sulphate of iron, as a useful way of combining the opium 
with a tonic, and at the same time avoiding any too astrin- 
gent action. The iron is precipitated as green carbonate, 
but this does not in any way impair the effect. Easton's 
syrup in doses of twenty or thirty drops three times a day, 
may be given afterward (syrupus ferri et quinise et strychnise 
phosphatum). It is better than the more usually prescribed 
Parrish's food under these circumstances, being less liable 
to upset the stomach. 

Lienteric diarrhoea does not yield to ordinary astringents, 
and is much increased by laxatives, as castor-oil. Opium 
checks it temporarily, but the best remedies are Fowler's 
solution and tincture of nux vomica in small doses. At 



DISEASES OF THE INTESTINES. 137 

the same time a digestible diet must be ordered at regulated 
intervals. Dr. Lewis Marshall thinks highly of the sali- 
cylate of lithia in these cases. 

Chronic diarrhoea in infants requires the expenditure of 
much thought and trouble if the treatment is to be suc- 
cessful. It is often obstinate, and improvement even in 
favorable cases very fitful. The treatment comprises diet, 
general hygiene and medicine. The diet must be regulated 
upon the lines already laid down for children in health.* 
Chronic diarrhoea is so much a disease of bad or too abun- 
dant feeding, that the first duty will probably be to see that 
starch is eliminated from the diet, or that milk is taken in 
reduced quantities. If milk should disagree, as it is liable 
to do even when diluted largely with water, or lime-water, 
milk and barley-water may be tried, and then whey or thin 
veal broth. But whatever is given must be in very small 
quantities — sometimes only a few teaspoonfuls — so as, if 
possible, to allow of digestion without starting the intestines 
into muscular action. If under these circumstances the 
child gains in weight, and the motions become more col- 
ored with bile and more consistent, it will probably get 
well; but the food must be carefully regulated, and only 
slowly increased in quantity. As the gastro-intestinal tract 
becomes more tolerant, the quantity of food given may be 
increased, the frequency of the meals decreased, and milk 
food be gradually reintroduced. In the worst cases all 
ordinary food must be stopped, and raw meat given instead. 
The directions given by Trousseau are as follows : Take a 
lean piece of beef or mutton, and after cutting it into small 
pieces, reduce it to a thin pulp with pestle and mortar. The 
pulp so made is passed through a fine colander, which will 
allow nothing to pass save the juice of the meat and fibrinous 

* For details, see " Diseases of Digestive Organs in Children.'' — Starr. 



I38 DISEASES OF CHILDREN. 

matter. This is scraped from the external surface of the col- 
ander, sweetened ; and, to begin with, a teaspoonful may be 
given three times a day; the quantity being gradually 
increased till five or six ounces are taken in the course of 
the twenty-four hours. 

It will often be found, however, that, except for the 
youngest infants, who take raw meat with avidity, it creates 
disgust, even when well sweetened. It is then to be given 
stirred up in a little cold veal broth or thin barley-water. 
It will usually be readily taken in this way when refused as 
a pulp. If not, it may be made into small masses, with 
confection of roses or currant jelly, or it may be mixed 
with chocolate made with water. At first the meat appears 
unchanged in the stools, but this soon alters and the meat 
becomes partially and then entirely digested, and the child 
gains in weight in proportion. 

In what may be called general hygiene, the child must be 
kept warm and clean. It should be wrapped in flannel 
and carefully guarded against cold feet and a cold stomach. 
It should be kept in one temperature, but in as pure air 
as possible, and all soiled linen should be removed from 
it at once. Medicines are comparatively of less value. 
They are by no meaes to be omitted, but careful diet 
and warmth are the essentials. Of drugs, opium is the 
most generally useful, and this may be well combined 
with logwood, ipecacuanha and chalk, as in the mistura 
haematoxyli co. of the Guy's Hospital Pharmacopoeia. A 
teaspoonful should be given every four hours if the diar- 
rhoea be profuse, and less frequently according to circum- 
stances. Another useful remedy is bismuth. For these 
cases, too, the wine of coca is sometimes useful ; and 
acorn coco, a preparation made from ordinary coco de- 
prived of its fat, and the soluble parts of roasted acorns, is 
a valuable remedial food. A teaspoonful is given three 



DISEASES OF THE INTESTINES. 139 

times a day, made as coco, but with water in place of 
milk. 

Sometimes astringents are useful — gallic acid, sulphate of 
copper, acetate of lead, may any of them be used according 
to the formulae given : — 

R . Acidi gallici, gr. x 

Vini opii, tt\, v 

Alcohol., fgiss 

Aquoe chloroformi, q. s. ad f 3 iss. M. 

Sig. — One teaspoonful three times a day. 

R . Cuprii sulphitis, gr. j 

Acidi sulphurici dil., f^ss 

Spirit, chloroformi, f 3 ss 

Syrupi, fgij 

Aqure cari, q. s. ad f 5 iss. M. 

Sig. — One teaspoonful three times a day. 

R • Plumbi acetatis, gr. viij 

Acidi acetici dil., TT\, xx 

Vini opii, TO^ x 

Syrupi, f 3 iij 

Aqure, q. s. ad f 5 iss. M. 

Sig. — One teaspoonful three times a day. 

Nitrate of silver is a most serviceable drug when the 
diarrhoea proves obstinate, aphthae appear in the mouth, 
and there is much thirst and prostration. One twenty- 
fourth of a grain may be given, suspended in syrup ot 
acacia, every two hours to a child of two years. Stimu- 
lants are also necessary to relieve the tendency to prostra- 
tion. Whiskey is the best, and it must be given in doses 
and at intervals proportioned to the demands of the indi- 
vidual case. Ten drops every two hours is about the 
average initial dose. 

Astringent enemata are recommended by some. They 
are not often retained, and are but seldom of use. Nitrate 
of silver, one grain to five ounces of water, is recommended 



140 DISEASES OF CHILDREN. 

by Trousseau ; but on the whole we are inclined to prefer 
equal parts of an infusion of ipecacuanha and decoction of 
starch ; or, starch and tincture of opium — two or three 
drops of the latter to two ounces of the vehicle. 

Injections of nitrate of silver, which, by the way, are very 
serviceable, should be given at intervals of twelve hours 
and preceded by an enema of warm water to wash out the 
rectum. After being continued for forty-eight hours, they 
should be discontinued for a day, during which the patient 
may receive, at the same intervals, injections of tincture of 
opium in starch water, three drops to half a fluidounce at 
the age of two years. 

When improvement sets in tonics must be employed to 
build up the general health. One of the best to succeed 
the treatment directed especially to the relief of the diarrhoea 
is the solution of the nitrate of iron with a mineral acid, 
for example : — 

R • Liquor ferri nitratis, 

Acidi nitrici dil., aafgss 

Syrupi zingiberis, f ^j 

Aquse, q. s. ad f^iij. M. 

SiG. — One teaspoonful three times daily, for a child of two years. 

Before using astringent injections, however, resort may 
be had to irrigation of the intestines. 

Dysentery. — This term is applied sometimes to chronic 
ulceration of the colon, sometimes to acute inflammation 
with the formation of diphtheritic membrane. In either 
case it is a disease which rarely attacks children, and does 
not differ from such affections in the adult. Extensive 
ulceration of the colon is almost always due to tubercular 
ulceration, though it is possible that it may be an occasional 
result of chronic diarrhoea. Dr. Goodhart has seen one 
case of acute colitis. The patient was a girl, aged about 
eleven years, who had been living badly. She was ex- 



DISEASES OF THE INTESTINES. I4I 

tremely prostrate, pale, and covered with a purpuric erup- 
tion. Her temperature was 100.8 . The spleen large. 
The bowels were confined at first, but the evacuations soon 
became watery, and pink from the presence of blood, and 
she sank rapidly; the temperature rising to 105.6 . The 
blood showed a reduction of more than one-half of the 
corpuscles and 65 per cent, of the coloring matter. At 
the inspection, the lower part of the colon and the rectum 
were the seat of a severe diphtheritic inflammation. The 
mucous membrane was swollen, coated with thick adherent 
membrane, the surface beneath being ecchymosed and 
bleeding. 

Such cases, when they occur, must be treated like bad 
cases of acute enteritis. For instance, some good may be 
derived from warm or cold applications to the abdomen. 
One or other of the various meat juices may prove of value 
as food ; and as drugs, small doses of ipecacuanha — either 
frequent drop doses of the wine or grain doses of the pow- 
der — or the tincture of coca, or glycerine of borax, may be 
recommended. 

For the less severe and more chronic cases, the dilute 

mineral acids, quinine, etc., may be of use ; and also any of 

the sugrcrestions that have been made under the head of 
00 

treatment of chronic diarrhoea. 

Abdominal Neuroses. — Under this heading Dr. Good- 
hart includes several disorders of digestion, some of which 
only can be considered as intestinal, nevertheless this posi- 
tion seems to be the most appropriate one for the section. 
In one set of cases fever is absent or very slight, but the 
tongue is furred, the breath foul, the appetite capricious, the 
bowels irregular, and superadded is a frequent dry hollow 
cough, which is often called a" stomach cough." The con- 
dition upon which these symptoms depend is a very indefi- 
nite one, if we attempt to treat of it pathologically, but 



142 DISEASES OF CHILDREN. 

distinct enough as a clinical fact. We have a dull, lan- 
guid state, with opaque and greasy skin, pallor and wast- 
ing. The tongue is flabby, moist, and covered with a 
whitish fur; the appetite is capricious — sometimes raven- 
ous, sometimes dainty, sometimes replaced by an inordi- 
nate thirst. There is a liability to severe stomach-ache, 
which in some children attacks them when they wake in 
the morning, in others appears to be excited by the inges- 
tion of food. The bowels are perhaps confined and relaxed 
alternately for days together. The constipation may 
attract but little attention, but the diarrhoea, particularly if 
combined with vomiting, makes the parents anxious. The 
child is said to be subject to bilious attacks ; or a dry, hol- 
low, frequent cough frightens every one around into the 
idea of consumption. Nor should this cough be passed 
over without alluding to the close sympathy that exists be- 
tween the stomach and the lungs. The diseases of the one 
organ are so frequently reflected in perverted functions of 
the other, that it is quite worth while bearing the fact 
in mind. It must not be supposed that all these symp- 
toms are to be found in any one case. Some children will 
require treatment for griping abdominal pain of a parox- 
ysmal kind, others for bilious attacks, others for pain in the 
side, others for cough, yet others perhaps for nightmare ; 
but when we come to investigate cases, certain other features 
are found in common — viz., pallor, wasting, furred tongue, 
foul breath, irregular bowels, etc. Now these are all symp- 
toms which might be due to a great variety of causes, 
and they are not associated with any known anatomical 
lesions. Nevertheless, as a group they have much con- 
stancy, and it becomes necessary to assign them a place, and 
for purposes of recognition, a name also, among gastro- 
intestinal disorders. Dr. Eustace Smith, in his " Wasting 
Diseases," proposes the name " Mucous Disease." He con- 



DISEASES OF THE INTESTINES. 1 43 

siders a soft, flabby, indented tongue, smeared over with a 
gum-like mucus, to be particularly characteristic ; and the 
side-pain, stomach-ache, etc., to be due to accumulations of 
mucus in the bowel, and its evacuation to be the cause of 
the periodical diarrhoeas. As an accurate picture of the 
affection we are now engaged upon, the student cannot do 
better than read the chapter referred to in Dr. Eustace 
Smith's book.* Dr. Goodhart hesitates to indorse the term 
" Mucous Disease," first, because he has not been able to 
satisfy himself of the discharge of any very large quantity 
of mucus from the bowel in such cases ; secondly, because 
it is by no means certain that mucus, even if it should col- 
lect, would give rise to such symptoms ; thirdly, were it to 
do so, it would still have to own some cause behind it. But 
no doubt these chronic gastrointestinal derangements are 
a part of the series which are so described. 

He states : " For my own part, I am persuaded that 
although they may seem to be caused by temporary con- 
ditions, such as errors in diet, these varied pains and aches 
are often but the expression of a constitutional build. They 
are an evidence of nervous instability, and they are found 
in nervous children or nervous families. By this I mean 
that children subject to these ailments are the offspring of 
those whose nervous systems are feeble or diseased ; of 
those who have suffered from, or who are closely related to, 
the subjects of fits, insanity, hysteria, neuralgia, rheuma- 
tism, or gout ; or if not, have in themselves given other 
evidence of unstable nerves in the convulsions of infancy, 
passionateness, morbid timidity, chorea or rheumatism. 
Such children have nightmare badly, somnambulism, noc- 
turnal incontinence of urine. Their moral nature is essen- 

* " Wasting Diseases," 3d edition, p. 199. 



144 DISEASES OF CHILDREN. 

tially angular. They are an odd lot. The gastro-intestinal 
disturbances that are met with have much in them to sug- 
gest a nervous origin. The insignificance of the exciting 
causes, the suddenness of the attack, the suddenness of its 
subsidence, the nature of the attack in many cases, even 
the presence of an excess of mucus, if that be a dominant 
symptom, each and all of these symptoms are compatible 
with enfeebled nerve control." 

The American editor favors Dr. Eustace Smith's view. 
The course of the affection is usually chronic, and during 
it, there are apt to be periodical attacks of vomiting and 
diarrhoea. Frequently dark circles appear about the eyes, 
which at times look almost as though painted with India 
ink. The face is subject to rapid changes of color, some- 
times it is " deadly " pale, as if syncope was imminent, at 
others the cheeks wear a circumscribed flush. The child 
is languid by day, restless by night, and sleep is disturbed 
by night terrors, his appetite is capricious, his abdomen 
large and protruding, presenting a marked contrast to his 
wasted limbs and body. The stools are scanty, infrequent, 
composed of small dry lumps of faeces, and contain a 
quantity of mucus, in which it is not unusual to find a 
number of thread worms. The periodical attacks, lasting 
one or two days, seem to be due to accumulation of mucus 
and partial retention of faeces; during them large quantities 
of both of these substances being voided, there is a tempo- 
rary improvement in the general symptoms. They are, 
therefore, to a certain extent, critical discharges. 

The symptoms of chronic indigestion are similar in nature, 
though less severe than those of mucous disease. In both 
conditions there is a catarrh of the gastro-intestinal mucous 
membrane, but that of mucous disease is by far the more 
intense. 



DISEASES OF THE INTESTINES. 145 

Diagnosis. — The abdominal pains which so often form 
the striking feature of the complaint are very similar to those 
present in many cases of early tuberculosis, or tabes mesen- 
terica, and these diseases are not always easy to distinguish. 
Mesenteric disease should be characterized by a greater 
fulness of abdomen, more persistent pain, less constipation, 
more wasting. On the other hand, tabes, in its earlier 
stages, is very liable to be overlooked if abdominal neur< 
with their fascinating capacity for fitting all measures, are 
allowed to usurp an undue proportion of the observer's 
imaginative faculties. 

It is of great importance to make an early diagnosis be- 
tween mucous disease and tuberculosis. In the former, the 
tongue is slimy and swollen, the bowels are constipated, the 
stools composed in great part of mucus, the skin yellow, 
dry, and rough, with exfoliating epidermis, and there is no 
pyrexia. Features distinct from those of tuberculosis. 
Should, however, fever occur in a case presenting the symp- 
toms of mucous disease, an event quite possible in the 
paroxysms of vomiting and purging, or during the course 
of some intercurrent disorder, it is necessary to make a 
careful examination of the lungs, and take the temperature 
for several days, to be sure of the diagnosis. 

Treatment. — On general principles these children require 
most careful feeding — not only must the material be super- 
vised, but also the amount taken and the way in which it is 
taken. They are to have plenty of milk and bread, sugar 
and butter in moderation, meat and fish ; but vegetables in 
small quantity. Potato may be given if it is carefully pureed 
with milk, so as to be almost fluid, but not otherwise. 
Boiled potato is very trying to a child's stomach. Next 
they require tonics, of which bicarbonate of potassium and 
tartrate of iron, of each gr. v with syrup and water, is very 
generally suitable. 



I46 DISEASES OF CHILDREN. 

R . Potassii bicarbonatis, ^j 

Ferri tartratis, gj 

Ext. glycyrrhizae fb, f^ ss 

Aquae, q. s. adf^iij. M. 

SlG. — Two teaspoonfuls three times a day. 

In the treatment of mucous diseases it is of the greatest 
consequence to regulate the diet. The child must be fed, 
so far as possible, on milk, meat, and eggs. As farinaceous 
food readily undergoes fermentation, and by the acids so 
generated, increases the catarrh, all articles of this class 
should be rigidly excluded except bread, and this must 
be eaten stale or toasted. After the child has reached 
the age of three years, a most satisfactory diet is such as 
this : — 

Breakfast — milk with lime-water (in the proportion of 
f gss— ij to Oss), a soft-boiled egg, and stale bread or toast. 
Time of meal, 7 to 8 o'clock, a.m. 

Dinner — roasted or broiled lean meat, occasionally a bowl 
of meat broth, and stale bread. Time of meal, midday. 

Supper — milk with lime-water and stale bread or toast. 
Time of meal, 6 to 7 o'clock, p.m. 

The quantity eaten at each meal should be moderate, and 
if the child become hungry in the intervals, a cup of milk 
and a small slice of bread may be given. When improve- 
ment begins, the diet may gradually be increased ; boiled 
potatoes, salted meats, molasses and pastry being among 
the articles to be allowed. 

But the special symptoms require special treatment. The 
abdominal pains which are so common, are almost invari- 
ably relieved by small doses of Dover's powders or by a 
carminative. They are not common in children under 
three or four years of age, so that two or three grains of the 
powder may be given twice or three times a day in most 
cases, and in older children four or five grains may be neces- 



DISEASES OF THE INTESTINES. 1 47 

sary ; and this treatment should be continued for at least 
ten days or a fortnight. 

For the various other pains and aches, bromide of potas- 
sium or ammonium is most generally suitable, and it may 
sometimes be advantageously combined with small doses 
of chloral. 

In mucous disease, should the loss of digestive power be 
in excess of the mucous flux, great advantage is derived 
from the combination of dilute muriatic acid, with one of 
the cinchona alkaloids, or with nux vomica. But if the 
opposite condition prevails, and mucus is vomited, or appears 
in the stools, alkalies are much more efficient than acids, 
as they have a tendency to arrest the formation of mucus, 
and at the same time, by neutralizing the acids formed by 
fermentation, to remove one source of irritation. The best 
alkali is the bicarbonate of sodium, administered in combi- 
nation with compound infusion of gentian or infusion of 
columbo, either bitter aiding the action of the alkali by its 
power of checking fermentation. Often after improving for 
a time under this treatment, a case comes to a standstill ; 
when this happens, the favorable progress may be reestab- 
lished by the substitution of dilute muriatic acid for the 
alkali. Iron in the following combination is often very 
useful : — 

U. Ferri sulph. exsiccat., gr. iv 

Tr. aloes et myrrbre, f 3 iv 

Syr. rhei aromat., q. s. adf^iij. M. 

A teaspoonful to be taken tbree times a day, for a cbild of three or four 
years. 

Both the iron and rhubarb tend to check the formation of 
mucus, and the aloes and the rhubarb clear the bowels of 
mucus. In the bronchitis of the larger tubes, an expecto- 
rant, such as chloride of ammonium, must be employed : — 



I48 DISEASES OF CHILDREN. 

R . Ammonii chloridi, . . _. g j 

Ext. glycyrrhizse pulv., gr. xij 

Syrupi simp., f^ ss 

Aquae, f Jiij. M. 

SlG. — One teaspoonful every two or three hours. 

In all cases the bowels must be kept open by some mild 
aperient, than which none can be better than the compound 
decoction of aloes, or ten-minim doses of tincture of podo- 
phyllin. A little Friedrichshall water taken in the morning 
is another purgative which some children take well. Later 
on, strychnina may be combined with the iron, either as the 
liquor, the tr. nucis vomicae, or as Fellows' or Easton's 
syrup. 

Rectal Polypus is not rare. It causes persistent and 
occasionally severe hemorrhage from the bowels, and some- 
times children are completely blanched by it. The polypi 
are usually solitary,' pedunculated and projecting from the 
mucous membrane some short distance above the internal 
sphincter. They are firm, fleshy bodies, composed of villous 
processes and crypts covered and lined by columnar epithe- 
lium, and in section they form beautiful microscopic objects. 
Although these polypi are nearly always solitary, Dr. Good- 
hart has known the whole of the rectal mucous membrane 
to be covered by them. 

Treatment. — The forefinger, well oiled, should be passed 
into the rectum, the polypus hooked down, and its pedicle 
frayed through with the nail. Polypi are, for the most 
part, easily detached. Should there be any difficulty in 
removing them in this way, they must be ligatured ; but 
this is seldom necessary. 

Intussusception is where one piece of intestine passes 
into a piece immediately continuous with it, the intussus- 
ception being the tumor so formed. In the common form 
the ileo-caecal valve and the lower part of the ileum are 



DISEASES OF THE INTESTINES. 1 49 

received into the colon, and the tumor is composed of the 
colon externally (ensheathing layer), the ileo-caecal valve and 
caecum within this (returning layer), and the lower part of 
the ileum, internally (entering layer). In this form, there- 
fore, the ileo-caecal valve is always the lowest part, and 
supposing, as is often the case, that the intussusception 
passes into the rectum, it is that part which is felt by the 
finger within, or which protrudes from the anus. Much 
more rarely a piece of the ileum passes through the ileo- 
caecal valve ; or some other part of the large or small intes- 
tine is affected at a distance from the valve. Further, as 
might be expected, the direction of the intussusception is 
almost invariably from above downward ; although one or 
two cases are on record in which the reverse direction has 
obtained, and a piece from below has passed into that which 
lies above it. 

Pathology. — It would be easy to occupy a good deal of 
space in discussing this question, but little good would be 
gained thereby. Attention must be called to one or two 
facts which seem to be all-important in their bearing. First, 
let it be noticed that by far the larger number of cases of 
intussusception occur in infants under two years of age — 
most of them under a year ; secondly, that small intussus- 
ceptions in the length of the small intestines are by no 
means uncommon in the bodies of children who have died 
of all manner of diseases, and it is clear, from the absence 
of any symptoms during life, and from the want of any 
local morbid appearance in the part concerned after death, 
that the displacements must have occurred at the time of 
death or but very shortly before ; thirdly, that the common 
seat of the affection which causes symptoms during life is 
ileo-caecal. 

Now, what do these facts indicate ? Not much, perhaps, 
as they stand, and yet they are very significant. Those who 
13 



I50 DISEASES OF CHILDREN. 

have been in the habit of seeing experiments performed upon 
the lower animals, well know that at the moment of death 
there is not infrequently a vigorous and persistent peristaltic 
action of the intestines. The same thing is apparent as a 
clinical fact in the evacuation of the bowel, which so often 
happens at the time of death in all classes of disease. This 
is no mere relaxation of the sphincters. They become re- 
laxed truly, but the weights of the buttocks and of the soft 
parts would be amply sufficient to restrain any outflow of 
fecal matter, were it not that the intestine acts vigorously 
and persistently after death. The intestine, so to speak, has 
a death struggle, and dies slowly ; and in so doing its mus- 
cle acts less regularly, and intussusception is an occasional 
consequence. It is impossible to watch a healthy infant for 
even a few minutes, and not see that in its every movement 
there is convulsion and disorder. The frequency of intes- 
tinal disorders in children is an expression of the same fact ; 
and so, also, no doubt, in large part, is the occurrence of 
intussusception. Intussusception is chiefly a disease of 
young children, because the muscular coat of the bowels is 
as yet too easily excited, and is prone to act irregularly and 
energetically. That the ileo-caecal valve and lower part of 
the ileum form the intussusception in so large a majority of 
the cases, is also worth consideration ; for the anatomical 
arrangement is such that it may be almost said to form a 
natural prolapse, or at the least would readily become one 
upon the slightest alteration of the natural relations of the 
parts either as regards their relative positions or relative 
capacity. It has been suggested that some congenital laxity 
in the attachments of the caecum, is the reason of the fre- 
quency of ileo-caecal invagination ; but, granting the con- 
dition, it is not clear that it would favor the occurrence of 
this particular displacement, and no proof has yet been 
given that any such condition exists. On the other hand, 



DISEASES OF THE INTESTINES. I 5 I 

the reasons already mentioned seem sufficient to explain 
the observed phenomena, and the more so if we allow- 
further for the possible passage of indigestible food or of 
inspissated fecal matter. 

Morbid Anatomy. — On opening the bodies of children 
who have died of intussusception, there may be nothing 
abnormal to be seen at first. The small intestine, more 
or less distended, occupies the front of the abdominal 
cavity, and the colon is not visible. When the small 
intestine is displaced, probably some twisted condition of the 
mesentery will become apparent, and the caecum and more 
or less of the colon will be found absent from their natural 
position. The colon will appear to take origin from a knot- 
like bulb of bowel, perhaps lying in the right loin or in some 
part of the transverse or descending colon. The small 
intestine passes into a node of bowel, and this when taken 
between the finger and thumb feels doughy and inelastic. 
The intussusception gives a livid appearance to the tumor, 
and there is often ecchymosis or lymph about the neck of 
the knot. The condition of the intussuscepted bowel will 
of course vary with the length of time that the affection has 
existed in an acute form. It is generally more or less 
twisted or coiled, from the inclusion of the mesentery ; of a 
dark claret color from congestion or extravasation of blood 
into its substance, or ash-colored from sloughing of the sur- 
face of the mucous membrane, and the coats of the included 
bowel are thickened by oedema and inflammatory products. 
Bearing in mind that the experience of the post-mortem 
room is based upon cases of exceptional duration or severity, 
it may be worth stating what have been the effects of post- 
mortem attempts at reduction in such cases. Inflation has 
never done more than partially reduce the intussusception ; 
hydraulic pressure applied by passing a half-inch bore india- 
rubber pipe, connected with the water-tap, up the rectum, 



152 DISEASES OF CHILDREN. 

and then gently turning on the tap till the requisite pressure 
is obtained, has reduced a bad case with ease ; traction upon 
the small intestine at the neck is not often successful ; and 
manipulation, such as that applied to a hernia, from outside, 
usually reduces the greater part of the prolapse, if applied 
with care, but fails to accomplish the return of the last two 
or three inches of bowel — the part about the neck of the 
intussusception having by that time become tight from the 
squeezing and traction combined, while the neck itself is 
liable to split. In two or three cases Dr. Goodhart has 
found it impossible by any means to effect complete reduc- 
tion without doing so much local damage as would have 
deprived an operation of any chance of success had the 
child been still alive. The chief obstacles to reduction are : 
First, the spiral twist or curve which the intussusception 
assumes around its mesentery, and which depends upon the 
inclusion of the mesentery. It is almost impossible, for this 
reason, to make any adequate traction upon the bowel in the 
proper axis. And, secondly, the swelling of the coats of 
the inclusion due to oedema, extravasation of blood, or the 
formation of inflammatory products, — occasionally lymph, 
— about the neck of the sac, or lymph between the peritoneal 
surfaces of the entering and returning layers, offer an 
obstacle to any return by direct traction ; but they do not 
usually offer much hindrance to reduction by other methods 
of manipulation, such as gentle pressure. 

The experience of the post-mortem room is on the whole 
decidedly adverse to the chances of reduction when the case 
has existed sufficiently long to produce much oedema or 
inflammatory thickening of the coats of the bowel. It may 
also be remarked that, suppose reduction is effected in any 
such case, there will still exist a more or less intense enter- 
itis in some inches of the bowel, which must make the 
prognosis uncertain for some days after. 



DISEASES OF THE INTESTINES. 153 

Symptoms. — Vomiting; the expulsion of blood and blood- 
stained mucus per anum; the presence of an elongated 
doughy tumor in some part of the colic region, or the pro- 
trusion of a polypoid mass of mucous membrane from the 
anus, or the detection of such a mass by rectal exploration; 
pain, and the sudden supervention of such symptoms of 
collapse as pallor, a sunken eye, and rapid pulse. 

These, it will be noticed, are the symptoms of strangulated 
hernia, with the substitution of the passage of bloody mucus 
in intussusception for the obstinate constipation of hernia. 
But, when we talk thus of the symptoms of intussusception, 
we are ignoring a very important clinical fact — viz., that the 
symptoms necessitate a recognition of two kinds of intus- 
susception — strangulated and non-strangulated — or, as some 
would have it, acute and chronic. 

An intussusception may exist without any constipation, 
without the passage of any blood or mucus, and indeed 
without any characteristic symptoms. Some years ago a 
child of ten months old was brought to Dr. Goodhart as 
an out-patient; it was cutting its teeth, was feverish, restless, 
and had a dry, furred, reddish tongue. The abdomen was 
full, but not tender; it was quite supple, and after careful 
examination nothing could be felt. There was no vomiting 
nor passage of blood. A few days after the mother came 
to say the child had died ; and, not knowing why such a 
result had happened, a post-mortem was made. Some form 
of enteritis was expected ; but, in addition thereto, there was 
an elongated intussusception of the ileum into the colon, 
occupying the middle of the transverse colon, of which there 
had been no suspicion. Other similar cases are on record, 
and others again where cholera infantum, typhoid fever, etc., 
have been mistaken for intussusception. It is, therefore, 
important to remember that, unless it be strangulated, the 
intussusception may be obscured by symptoms of catarrhal 



154 DISEASES OF CHILDREN. 

enteritis. A careful examination of the abdomen and 
rectum for the presence of a tumor is the best safeguard 
against such a mistake ; but even this may mislead, the 
small intestine becoming distended and hiding the colon. 

The symptoms of strangulation of the intussusception are 
usually well-marked. Although the child may have been 
ailing previously, the onset of acute symptoms is usually 
sudden. There is the cry of pain, obstinate vomiting, fecal 
retention, but the passage of blood or bloody mucus. And 
in addition to, or even before these, there is the aspect of 
severe illness, which comes on early, and is well worth at- 
tention, as suggestive of serious mischief, when other more 
distinctive features are yet in abeyance. Vomiting is so 
common an affection in infancy that it is liable to pass with- 
out much attention ; but vomiting, with restlessness and 
abdominal pain, and the quick onset of extreme pallor and 
a sinking hollow under the eyes, are a trio which should 
always compel attention. Death from intussusception may 
ensue with no other symptoms than these within twenty-four 
or thirty-six hours. With regard to the presence of blood 
in the evacuations, it has been shown by Dr. Hilton Fagge 
and Mr. Howse,* that it does not necessarily mean strangu- 
lation of the intussuscepted bowel in the sense that we 
speak of a strangulated hernia — viz., as the preliminary ot 
gangrene ; for it may be present, even from the first, in 
cases where the symptoms run a chronic course, and where 
even at last no gangrene or ulceration of bowel is found. 
It may, however, be concluded that it indicates some con- 
striction of the vessels. Such a condition is compatible 
with the preservation of the life of the tissues involved, 
particularly if the constriction is, as is probably not uncom- 



* " On Abdominal Section of Intussusception in an Adult." Medico-Chir. 
Trans., vol. lix. 



DISEASES OF THE INTESTINES. 155 

mon, intermittent. It has also been pointed out that in 
many of the cases in which the bowel has sloughed away 
no blood has been at any time present in the motions. The 
symptoms have been those, indeed, of enteritis or perito- 
nitis, and not those supposed to be characteristic of intus- 
susception. 

The confirmation of the diagnosis is not the only advan- 
tage derived from ascertaining the presence of an abdominal 
:umor. It has been asserted that by observing the behavior 
3f the tumor we may also learn something of the condition 
Df the invagination ; that if the tumor changes its position 
"rom time to time, we may conclude that the intussusception 
!s not yet adherent, and therefore has not yet commenced 
:o separate by sloughing. But it cannot be inferred that, 
Decause the tumor thus alters its position, therefore it can 
De reduced. The parts may not be sloughing — may not 
perhaps even be adherent — and yet may be so cedematous 
Dr inflamed as to be incapable of reduction ; and in infants, 
when separation of the intussusception by sloughing offers 
no chance of recovery, we want to know whether, in any 
particular case, the intussusception is reducible, and for 
this, any change in the position of the tumor offers no 
trustworthy guide. 

To sum up with regard to the symptoms. Intussuscep- 
tion may exist for weeks, perhaps even for months, without 
giving rise to any severe illness, and may be characterized 
only by periodical attacks of constipation, abdominal grip- 
ing, and vomiting, and by the occasional passage of a little 
blood. Palpation of the abdomen should reveal the pres- 
ence of an elongated tumor, which alters in position, in 
shape, and in hardness from time to time. But, as com- 
monly seen, intussusception is an acute affection which runs 
its course in at most three or four days, and the more usual 
symptoms are abdominal pain and distention ; vomiting, 



I56 DISEASES OF CHILDREN. 

fecal retention ; the passage of blood-stained mucus ; and 
often the presence in the rectum of a tumor with character- 
istic features. 

Course and Duration. — The natural tendency of every 
intussusception is to become nipped at its neck by the bowel 
which insheathes it, and sooner or later to become inflamed 
and to slough off. Sometimes the nipping is delayed for a 
time, and the sloughing-off process is almost never effected 
in infants. The spontaneous cure of an intussusception by 
sloughing of the invaginated mass is a result which may be 
hoped for in children of six or eight years, and in adults ; 
but in infants under two years the disturbance set up by 
the inflammation of the bowel is almost invariably fatal in 
from thirty-six hours to three or four days — unless it can 
be remedied by treatment. 

Prognosis. — When the onset is acute, the treatment is 
generally unsuccessful, and the child dies ; but enough cases 
have terminated favorably to allow of a certain amount of 
hope. 

In chronic cases the issue is more doubtful ; the risk of 
the ultimate supervention of strangulation must evidently 
be considerable ; but some cases seem to right themselves 
under treatment, and of this the following case is probably 
an instance. 

A boy of three and a half years was suddenly seized one 
evening with pain in the abdomen, which caused him to 
scream violently, and he vomited frequently. These symp- 
toms continued for three days and two nights, when he got 
quite well. He passed no blood by the bowels. Three 
months later, he was taken in the same way, and this time 
he passed a little blood from the bowels without any strain- 
ing. For three weeks he vomited repeatedly, and passed 
frequent loose motions, but no blood. The vomiting then 
ceased for a day or two, but as it returned again, he was 



DISEASES OF THE INTESTINES. 157 

brought to the hospital. He had had a great deal of castor- 
oil. He lay quiet in his mother's arms, but frequently cried 
with abdominal pain, which came on in paroxysms. His 
lips and tongue were dry and furred; pulse 120. On ex- 
amining the abdomen, it was not distended, but midway 
between the ensiform cartilage and the umbilicus there was 
an elongated sausage-like tumor, rather ill-defined in its 
outlines, but yet suspiciously like an intussusception. He 
was taken into the hospital under the author's colleague 
Dr. Taylor, who agreed with this diagnosis. He was put 
upon small doses of opium and fed carefully, when the pain 
subsided and the tumor slowly disappeared. He was kept 
under observation for six weeks, and at the end of that time 
no lump could be felt in any part of the abdomen, except in 
the region of the caecum, and this was attributed to a fecal 
collection. Dr. Goodhart has notes of other similar cases. 

Treatment. — This differs somewhat at different ages. By 
some means or other the invaginated portion of an acute 
intussusception must be returned. Deodorized tincture of 
opium should be given in drop doses as often as necessary 
to quiet the action of the bowel. Small doses of belladonna 
and hydrocyanic acid may also be found useful. The abdo- 
men should be covered with a warm fomentation or good 
warm poultice. 

If the symptoms are not relieved by such measures, 
reduction must be attempted without any delay, either by 
manipulation, by inflation, or by the injection of water or 
oil. In any case, an anaesthetic should be administered. 
When the abdominal muscles are well relaxed the tumor 
may be kneaded between the hands — possibly it may be 
fixed between the fingers and thumb of the right hand, and 
gently squeezed. In this way an intussusception may be 
partially reduced, but I have not seen complete reduction so 
effected. Inflation is effected by a bellow's. To this a stout 
H 



I58 DISEASES OF CHILDREN. 

piece of india-rubber tubing, with a vaginal end, is attached, 
and passed well into the rectum. The buttocks are held 
tightly round it, and air is then pumped into the colon ; an 
assistant at the same time gently manipulating the surface 
of the abdomen. The amount of force required must de- 
pend upon circumstances. Replacement of the bowel can 
usually only be effected by considerable distention of the 
whole colon, and distention of the colon sometimes requires 
a good deal of rather forcible pumping to compass it. 
There are now on record many cases of success by this 
means, but on the whole we prefer distention by water to 
that by air, partly because the pressure is more uniform, 
and partly because, in the event of the occurrence of rup- 
ture of the bowels, the escape of sterilized water is attended 
by less risk of peritonitis than would be the escape of air. 

In forced injection the practice usually employed is to 
use an ordinary enema apparatus, and throw into the bowel 
as much tepid water as may be possible or necessary. 
Nothing appears more simple or easier to carry out 
efficiently than this plan, but as a matter of practice it is 
generally difficult to inject enough water with a force so 
carefully graduated as to be harmless, and yet sufficiently 
continuous to be successful. In many cases the greater 
part of the rectum is already filled by the intussusception, 
and the water returns by the side of the tube as fast as it is 
injected. No adequate distending force is exerted in such 
a case. It is much better to connect the metal tube with 
an improvised water-cistern placed high above the bed, for 
in this way is obtained a more equable and forcible disten- 
tion. The water used should be first boiled and then cooled 
down to a temperature of ioo° F. By this means Dr. 
Goodhart has reduced an intussusception that was well down 
into the rectum, the child, of course, being at the same 
time completely anaesthetized and having its buttocks 



DISEASES OF THE INTESTINES. 1 59 

elevated on pillows. Operations of this kind must be con- 
ducted with great care, as there is danger of rupturing the 
bowels from the great force brought into play. But then 
what are the alternatives? If left alone, the child will 
probably die. If the abdomen be opened and the bowel 
returned, it will probably sink within a few hours of the 
operation ; so that no risk can well be greater. It would 
be folly to affirm that any distention of the bowel, suffi- 
ciently forcible to return any considerable length of an 
intussusception, is free from risk ; and both inflation and 
the injection of water are very liable to split the peritoneal 
covering of the intestine and may rupture the bowel ; still, 
provided that the requisite distention cannot be procured 
without it, the end assuredly justifies the means. Mild 
means are to be attempted in the first instance ; these include 
opium, given internally; manipulation; inflation under 
ether; and copious enemata. Next in severity may be 
placed the more forcible distention described ; and not till 
all other measures have been tried and have failed should 
the abdomen be opened. 

With regard to the operation of laparotomy, the results 
at present are that but few cases have been successful out of 
many. Nor can an operation of such magnitude, performed 
upon subjects of such tender age, no matter what improve- 
ments are adopted, ever be otherwise than very dangerous. 

But there may still be a future in store for it, if all un- 
necessary delay is avoided. Intussusception is so usually 
fatal that it should be taken in hand at once and treated ; 
and, if the treatment be unsuccessful, the abdomen should 
at once be opened. Early operation gives the best security 
against finding the intussusception irreducible, and the pro- 
longed operation which irreducibility involves has probably 
had much to do with the great fatality which has hitherto 
attended the resort to surgical measures. The method of 
operation is a surgical question ; and it is only necessary here 



i6o 



DISEASES OF CHILDREN. 



to say that it consists in making an incision in the median 
line of the abdominal wall, opening the peritoneum, finding 
the intussusception, and working it back at the neck, much 
as a hernia is reduced. Sometimes traction reduces it readily. 
Antiseptic precautions should be adopted, but great care 
should be exercised not to expose the surface of the child 
to cold. There is a tendency to neglect this precaution 
in the present age of sprays and vapors, though few are 
more absolutely essential for the well-being of the child. It 
is certain that if abdominal section is to be successful in 
infants, the operation must be conducted with all possible 
celerity, and the surface — while it is going on — must be 
uncovered as little as possible. 

Prof. John Ashhurst, Jr., in an article on " Laparotomy for 
Intussusception," in the American Journal of Medical Sci- 
ences, July, 1874, gives a table of thirteen previously reported 
cases of laparotomy for invaginated bowel. From this table 
five cases have been extracted ; these occurred in children, 
and Prof. Ashhurst's conclusions are as follows : — 



6 

< 
3 


Sex 

AND 


Opera- 


Symptoms before 
the 


Duration 
of 


H 


in 

O h H 

H < 5 


Remarks. 


Age. 


tor. 


Operation. 


Disease. 


►4 



«2a 




O 










a 


*3c 




5 


Male, 


Gerson. 


Symptoms of ob- 


Not 


Died. 


A few 


Bowel ruptured, 




12 




struction, with 


mentioned 




hours. 


and operation 




weeks. 




hemorrhage from 
the bowels. 








abandoned. 


8 


Child, 
4 mos. 


Spencer 
Wells. 


Not specified. 


4 days. 


Died. 


5 hours 


Child almost 
moribund at 
time of opera- 
tion. 


11 


Child. 


Athol 
Johnstone. 


Not specified. 




Died. 






12 


Female, 


Wein- 


Symptoms of ob- 


3 days. 


Died. 


6 hours 


Died in convul- 




6 mos. 


lechner. 


struction, with 
great pain.vomit- 
ing, and hemor- 
rhage from the 
bowels. 








sions ; perito- 
nitis found at 
autopsy. 


13 


Female, 


Hutchin- 


Symptoms of ob- 


1 month. 


Recov- 




Disinvagination 




2 years. 


son. 


struction merely; 
intussusception 
protiuded from 
anus. 




ered. 




effected with- 
out difficulty. 



DISEASES OF THE INTESTINES. l6l 

" Inspection of this table shows, in the first place, that 
there is no encouragement to repeat the operation in very 
young infants. The only instances in which it has been 
resorted to during the first year of life have all terminated 
fatally (Gerson, Wells, Weinlechner.). But when it is re- 
membered that of Pilz's 162 cases (all occurring in children) 
no less than 91 were in infants less than a year old, it will 
be seen how large a proportion of cases must at once be put 
aside as unfitted for operative treatment. It is very true that 
the fatality of intussusception at this early age is enormous, 
the mortality being, according to Leichtenstein's elaborate 
statistics, no less than 86 per cent. But the case is very 
different from that, for instance, of an operation for imper- 
forate rectum, for in this condition there is necessarily no 
hope but in an operation, whereas in the case of intussus- 
ception experience shows on the one hand that, even at this 
age, a certain number do recover without operation, and 
that on the other hand, as might be expected, operative 
treatment is in such cases of no avail. 

" In the second place, the table shows that in what may 
be called acute cases, those, namely, in which in addition to 
symptoms of obstruction there are evidences of strangulation, 
such as peritonitis and intestinal hemorrhage, a resort to 
operative interference will be productive of no benefit. 
These cases are, on the one hand, as justly remarked 
by Mr. Hutchinson, precisely those in which there is 
most hope of recovery by sloughing of the invaginated 
portion. 

" There remains then a limited number of cases, in not 
very young infants, in which the symptoms are those of 
obstruction merely, without intestinal hemorrhage or perito- 
nitis, and in which, when other measures fail, the question 
of operation may properly be considered." 

From additional cases collected since the compilation of 



1 62 DISEASES OF CHILDREN. 

the above table, Prof. Ashhurst finds no data for altering - 
the conclusion already referred to. 

In chronic intussusception great reliance may be placed 
on the free administration of opium and belladonna. This 
form of intussusception occurs usually in older children, 
and four or five drops of opium and ten drops of tincture 
of belladonna may be given every four hours to a child of 
five or six years old. Should these fail, inflation or water 
distention must be tried, and as a last resort an operation 
must be discussed. 

In both forms of intussusception it is important to so 
regulate the diet that the strength may, as far as possible, 
be conserved. The quantity of food must depend upon 
the condition of the stomach, and in selecting the quality 
it is necessary to choose what is really digested and so 
assimilable that little residue remains to form fecal masses. 

Worms. — Four varieties of worms infest the alimentary 
canal of children — the oxyuris vermicularis, the ascaris 
lumbricoides, the taenia mediocanellata, and the taenia 
solium ; named in the order in which they are most fre- 
quently met. The first two are nematodes or thread worms, 
and are much more common than the cestodes or tape- 
worms. The oxyuris vermicularis or small thread worm 
inhabits the colon, particularly of children. There is some 
difference of opinion as to which part of the colon is most 
frequently infested. It has been generally taught that the 
sigmoid flexure and rectum are the favorite habitat of this 
parasite; but Cobbold and others now assert that the caecum 
is its home. It is a fusiform or whitish worm, the female 
being from a quarter to half an inch in length. The male 
is smaller, and usually with a curl of its more blunted tail. 
The eggs are oval, with the surface flattened, and usually 
contain a formed embryo. They are said to be introduced 
by the mouth and hatched in the stomach, whence they 



DISEASES OF THE INTESTINES. 1 63 

pass onward to the large intestine. According to Kiichen- 
meister one person is a sufficient host for all stages of the 
worm, but Leuckhart considers that the ova must be dis- 
charged and taken into the stomach, there to be partially 
digested, and the embryo set free before the worm can 
come to maturity. This is not a question of much import- 
ance, for it is admitted that one and the same child can act 
the part of a second host by re-infecting itself — an easy 
matter — by means of the fingers, which are used indiscrimi- 
nately for scratching the irritated outlets and conveying 
food to the mouth. 

The ascaris lumbricoides, a round worm, is not at all 
unlike the common garden worm, but paler and more taper- 
ing. The male measures four to six inches, and is smaller 
than the female. The latter is ten or twelve inches in 
length, and is often seen, when it has been subjected to 
slight pressure, with a bundle of processes hanging from its 
ventral surface ; these are the extruded ovaries. The eggs 
are oval, -g-^j- inch in length, have a nodulated shell, are 
produced in large numbers, and do not contain a formed 
embryo at the time of their discharge. It is important to 
bear the characteristics of the ova in mind, because the 
round worm is somewhat obstinate in resisting treatment. 
It does not reveal its presence in the stools as a seething 
mass of thread worms do, and microscopic examination of 
the stool may be necessary to determine its presence. It 
inhabits the small intestine, and is seldom solitary. Any 
number may be found, often from two or three to five, and 
occasionally much larger numbers. The ova are very 
indestructible, they remain dormant for a long period, and 
in this state, or perhaps some other intermediate larval one, 
are taken into the stomach by means of unwashed food and 
unfiltered water. 

The tapeworms (taenia solium and taenia mediocanellata) 



164 DISEASES OF CHILDREN. 

are far less common than either the ascaris lumbricoides or 
the oxyuris, but they are occasionally present even in infants 
if they have been weaned, and in older children they are not 
uncommon. Inasmuch as the same treatment is efficient 
for both T. solium and T. mediocanellata, and the symp- 
toms do not differ for either, it is not a matter of much 
practical moment to distinguish between them, but, shortly 
stated, the taenia mediocanellata or beef tapeworm is much 
more common than the taenia solium or pork tapeworm ; 
it is thicker and tougher generally ; it has a uterus which is 
much more finely subdivided, and the head is provided with 
suckers but not with hooklets. The anterior sucker of the 
taenia solium is provided with hooklets. The ripe segments 
or proglottides are passed, and the ova distributed in this 
way. They are then swallowed and become the cysticercus 
of the next host, the cysticercus in turn becoming the 
mature tapeworm by passing with food, etc., into the in- 
testinal canal of man. Tapeworms require nine or ten 
weeks to reach maturity, so that if, after the administration 
of anthelmintics, the worm passes minus its head, that time 
will probably elapse before segments again begin to appear 
in the faeces. Some time ago, a girl of eleven years old 
was under treatment at the Evelina Hospital for tapeworm. 
The oil of male fern effected the passage of a great length 
of worm, but not of the head. She was directed to take no 
more medicine until she should again see the joints of the 
tapeworm, when she was to return, and on several subse- 
quent occasions, the treatment failing to procure the expul- 
sion of the head, she reappeared at intervals of nine to 
eleven weeks. 

Florence C, aged eleven, came first under Dr. Goodhart's 
care on June 18, 1878. A drachm of the oil of male fern 
was prescribed in the usual way with castor-oil. She reap- 
peared on September 6, and was under treatment till the 



DISEASES OF THE INTESTINES. 1 65 

24th ; from November 29 she was under treatment till De- 
cember 6 ; from February 14 till May 2 ; July 1 1 till Sep- 
tember 20; on December 12 she came again, and at this, 
her last attendance, she took three drachms of the ext. filicis 
liquidum for a dose. In every instance the worm was de- 
tached close up to the head, but the head itself was never 
found. 

Symptoms and Diagnosis. — All sorts of symptoms have 
at one time or another been ascribed to worms. They have 
mostly been nervous, such as convulsion, epilepsy, cramp, 
choreic movements, or nightmare, and have been supposed 
to be due to some reflex nervous discharge set going by the 
local irritation. But it is very doubtful whether any are of 
diagnostic importance. The presence of worms can only 
be determined with certainty by finding them or their ova 
in the evacuations or about the anus. The habit of picking 
the nose is the popular indication, but it is often no indica- 
tion at all. Pruritus ani is of more value, and when it is 
observed should always lead to a careful inspection of the 
faeces, and even to the use of enemata with the view to de- 
tecting the worms themselves. Of other symptoms, such as 
irregularity of pupils, discoloration round the eyes, tumidity 
of the abdomen with colicky pains, diarrhoea, variability of 
appetite, etc., only need to be mentioned to show that they 
can have no special significance, although they may prob- 
ably be some of the many symptoms of feeble health, 
impaired digestion, and irregularity of the bowels, which 
are often present where worms abound. The ascaris lumbri- 
coides, however, inhabiting, as it does, the small intestine, 
and often in large numbers, is apt to wander into the 
stomach, and is sometimes associated with very acute symp- 
toms. Sudden attacks of fever and vomiting are apt to 
supervene and to assume even an aspect of a bad form of 
gastritis or of grave cerebral disease, when a round worm is 



1 66 DISEASES OF CHILDREN. 

vomited, or perhaps many, and the disturbance is at once 
at an end. The round worm would seem to be particularly 
prone to induce convulsions, nor need one wonder that 
such is the case, inhabiting the intestine, as they may do, by 
hundreds, and at a time of life when the nervous system 
has not reached the stable condition it assumes in healthy 
adult age. Dr. West has, however, seen very severe con- 
vulsions with thread worms, and other authors have equally 
noticed the liability to nerve disturbances which exist with 
the tapeworm. 

Thread worms, collecting in great numbers in the rectum, 
are apt to excite local irritation, mucous diarrhcea, prolapsus 
ani, and the occasional passage of blood from the bowels. 
In the male they may excite priapism, and some of the symp- 
toms of stone. Frequent micturition is a common symptom 
of their presence, and the author has occasionally noticed 
haematuna also, and the uneasy sensations about the genital 
organs may induce the habit of masturbation. In the female, 
a purulent discharge from the vagina is by no means uncom- 
mon. Worms of any kind are liable to occasion a mucous 
diarrhcea, associated with a good deal of tenesmus. 

Tapeworms give rise to fewer local symptoms, but they 
are more often associated with progressive and even marked 
emaciation. 

The symptoms of worms not being pathognomonic, it is 
impossible to make a diagnosis off-hand. Supposing that a 
child is emaciating slowly, has a frequent cough, occasional 
diarrhcea, perhaps febrile attacks, and sleeps badly at night, 
it might equally well be suffering from commencing tuber- 
culosis as from worms. It is indeed only by observation 
that the question can be settled. In all cases of doubt an 
aperient should be given, and the evacuations carefully 
examined. Treatment of this kind should in most cases 
clear up the difficulty. 



DISEASES OF THE INTESTINES. 167 

Treatment. — Worms usually accompany a state of health 
which, if it cannot be called bad, is yet below a normal 
standard ; and, for one child in whom nothing but health 
can be detected, there will be many who are pale, thin and 
unkempt. Possibly in the case of tapeworm the feeble 
health may in part be due to the presence of the parasite, 
but this can hardly be the case for other forms of worms, 
and, therefore, the existence of any form of intestinal para- 
site may be considered an evidence of the need of tonic 
treatment and better hygiene. As a general prophylactic, 
salt is to be commended, and this, by the way, is a neces- 
sary article of diet, which is much neglected in feeding 
children. But general principles of this kind must be 
associated with special treatment directed to the death and 
expulsion of the worm, and this will vary for the different 
species. 

Thread worms should be attacked locally by means of 
enemata. A drachm of sulphate of iron may be added to a 
Dint of infusion of quassia, and a third part of it injected on 
alternate mornings. Simple salt and water is recommended 
by some, lime-water, or alum (5j to Oj), by others. 
Enemata of this kind can be continued as long as may be 
necessary, and are moderately certain of success. But 
mothers and nurses often bungle over their administration, 
and either frighten the child so much that repetition of the 
treatment is impossible, or the fluid is allowed to run away 
again as soon as it is injected, when naturally enough a 
failure results. The lower bowel should be first emptied 
by an injection of warm soap and water. The child should 
lie upon a bed with its buttocks elevated. The enema is 
best administered by a Lund's inflator, the tube being 
passed carefully to the upper part of the rectum, and any 
expulsive efforts that may be excited are neutralized by the 
anal air pad, which is one of the features of this instru- 



1 68 DISEASES OF CHILDREN. 

ment. In this way the fluid may be made to reach a con- 
siderable part of the colon, and the remedy is so much the 
more likely to be effective. The enema should be retained 
as long as possible. If, however, the opinion be correct 
that the worm resides chiefly in the caecum, brisk purga- 
tives, such as calomel with jalap, must be resorted to, as, 
of course, in that way only can a radical cure be effected, 
unless, indeed, intestinal irritation, as already described, 
should prove to be all that its advocates claim for it. The 
following prescription will be found useful : — 

R. Hydrargyri chloridi mit, gr. j 

Resinas jalapse, gr. ij 

Pulv. scammonii, gr. v. 

M. et ft. chart. No.i. 
Sig. — For one dose at the age of six years. 

Enemata may be combined with an internal treatment of 
sulphate of iron and compound decoction of aloes, and 
iron in some form should be continued for a time after 
the extermination of the worms. The irritation about 
the rectum is best relieved by smearing the parts with a 
combination of mercurial ointment and glycerinum acidi 
carbolici in equal portions. Other good prescriptions for 
this purpose are : — 

R. Cocaine hydrochlor., gr. iij 

Bismuthi subnitrat., gr. x 

Vaseline, 3J. M. 

R . Santonini, gr. iij 

01. theobrom., gj. 

M. et ft. supposit., No. vj. 
SiG. — Use one morning and evening. 

The round worm is best treated by santonine, which may 
be given in doses of one-half to one grain three times a day, 
at the age of two years, either disguised in bread and honey, 



DISEASES OF THE INTESTINES. 1 69 

or in a teaspoonful of confection of sulphur or confection of 
senna. After two days of this treatment some purgative 
should be administered, one tablespoonful of castor-oil emul- 
sion, or one grain of jalap resin in milk, being as good as 
any. The officinal santonine tablets, each containing one 
grain, furnish an agreeable method of administering the drug. 
Other remedies are fluid extract of senna and spigelia 
and oil of chenopodium. With the first it is not necessary 
to give a purgative. The second may be given dropped 
upon a lump of sugar, three times a day ; the third dose 
being followed by a brisk cathartic, or, it may be, adminis- 
tered in the form of an emulsion with castor-oil, thus: — 

R . Olei chenopodii, f 3 ij 

Oleiricini, ^3 SS 

Oleicinnamomi, n\,v 

Mucilag. acacire, q. s. ad f.^iij. M. 

SiG. — One teaspoonful three times daily, for a child of two years. 

A tonic treatment of iron is to be continued for some time 
after the dislodgment of the worms. 

Many drugs have been proposed for the destruction of 
tapeworms, turpentine, cusso, and male fern being most 
prominently supported. But with children, as with adults, 
although it is advisable to have many strings to the bow, 
the oil of male fern is the one remedy in almost exclusive 
use. It is a drug which is apparently harmless even in 
doses of considerable size. Half a teaspoonful or more of 
the liquid extract is a proper dose for a child of six years. 
It may be given as an emulsion with 5ss of pulv. traga- 
canth. co.* either in milk or in any sweetened aromatic 



* Pulvis Tragacanthre Compositus, B. P., contains : — 
Tragacanth, in powder, 
Gum acacia, in po\ 
Starch, in powder, 
Refined sugar, in powder, 3 ounces. — Ed. 



owder, ) 
)Owder, V 
*, J 



170 DISEASES OF CHILDREN. 

water that may be pleasant to the child. The anthelmintic 
must be given after a fast, and with the intestine previously 
emptied of its contents by castor-oil. After an early tea 
the castor-oil should be given, and the next morning, as 
early as possible so as to avoid too prolonged a fast, the oil 
of male fern ; the child lies quiet in bed the while, and two 
or three hours later a second dose of oil is given, after which 
food may be given when required. Should this treatment 
fail, turpentine should be given — twenty drops of oil of tur- 
pentine three times a day — the food being confined to 
liquids. The turpentine may be given in emulsions, and 
must be followed up by a purgative every day or two. 

Powdered kameela, given in syrup, and pumpkin-seeds, 
beaten up with sugar into an electuary, are also used. 
These are sometimes more successful than male fern. The 
dose of kameela is twenty grains to a drachm ; of pumpkin- 
seed, from one to two drachms ; each to be followed by a 
purge. 

For a long time the bark of the pomegranate root has 
been known as a remedy for " taenia," or tapeworm ; but 
the difficulty of procuring it fresh, the short time it keeps 
good, and the unpleasant taste of the decoction, has greatly 
limited its use. Besides, it has been ascertained that its 
action is variable, according to the season of collecting, the 
age and vigor of the tree, etc. It is this uncertainty that 
compelled Professor Laboulbene, Member of the Academy 
of Medicine, who has made the cure of taenia a specialty, 
and who considers the bark of pomegranate root the best 
and most efficacious remedy, to say : " I wish that some one 
would discover and separate from the taenicide plants a 
sure alkaloid always identical, and that would act with cer- 
tainty, which is something we cannot obtain from pome- 
granate bark, or from old kooso, which is nearly inert." 

Mr. Tanret has found this alkaloid, and for his discovery 



DISEASES OF THE INTESTINES. I/I 

has been awarded the " Barbier Prize" by the Academy of 
Sciences. He calls it Pelletierine, in honor of the illustrious 
chemist, who, with Caventou, has made numerous discov- 
eries in organic chemistry of great benefit to humanity. 

Tanret's pelletierine has given the most satisfactory re- 
sults in the hospitals where it has been tried, for instance, 
at the Marine Hospitals of Toulon, St. Mandrier, etc.; and 
in Paris, St. Antoine, La Charite, Nccker and Beaujon, etc. 
Dujardin-Beaumetz, Member of the Academy of Medicine, 
declared to the Society of Therapeutics, that he was suc- 
cessful in thirty-two cases out of thirty-three treated with 
pelletierine, and Professor Laboulbene was successful in 
every case he used it, fourteen in all. 

Pelletierine is dispensed in bottles containing the proper 
dose for an adult, and one dose is usually sufficient. For 
children from nine to twelve years, half the adult dose is 
sufficient. 

In administering the drug, certain preliminaries are indis- 
pensable to insure success. 

When pieces of tapeworm are or have been ejected 
within a short time after some other remedy has been taken 
without expelling the head, pelletierine should not be taken 
until some pieces of the worm are again noticed. 

In the evening the patient must use a large laxative injec- 
tion, and place himself on milk diet. The next morning, 
mix the contents of a bottle with a glass of sweetened water, 
and administer at one dose; three-quarters of an hour to an 
hour after, give one ounce compound tincture of jalap, 
mixed with one-half a glass of sweetened water. For 
women, the dose should be reduced to 20 grammes, and 
for children a still further reduction is necessary. The pur- 
gative, compound tincture of jalap is the best, but it can be 
substituted by any other cathartic. 

If the bowels are not relieved in a few hours after taking 



172 DISEASES OF CHILDREN. 

the purgative, then take either another purgative or an in- 
jection made of sulphate of sodium. A few minutes after 
having taken pelletierine there will be a sensation of giddi- 
ness, and the entire tapeworm will be passed from two to 
four hours after the remedy has been taken. 

4. DISEASES OF THE LIVER. 

There is not much to be said on this head. The liver is 
not an organ which is frequently diseased in childhood, 
though perhaps there is no one of the hepatic diseases of 
adult life which may not, as an occasional thing, find a home 
or have its birth in children. 

The most common affection would seem to be simple 
jaundice,* which may be found at any age — at birth, when it 
is called icterus neonatorum, and in older children, when it 
may be due to a variety of causes, but is, perhaps, chiefly 
" catarrhal." 

Icterus Neonatorum is of two forms, physiological and 
morbid. In the one case it is merely a yellowness of the 
surface, due to changes which ensue in a congested skin at 
the time of, or soon after, birth. It is said to be more fre- 
quent in premature infants. In this case, the conjunctiva 
and urine remain free from color, and the faeces retain a 
natural appearance. It passes off* within a few days, and is 
not of any moment. It requires no treatment. 

Icterus due to disease is a more serious matter, but the 
outlook will depend greatly upon the nature of the cause of 
the jaundice. In some cases it appears to be due to a simple 
catarrh of the ducts, or to some defective circulation in the 
liver in the first few days of life, or to exposure to cold, it 
being particularly frequent in foundlings. This condition 

* While, of course, jaundice is merely a symptom, it seems best to follow 
the old plan and give it separate consideration. — Ed. 



DISEASES OF THE LIVER. 1 73 

may all be expected to pass off by warmth, and some gentle 
laxative, such as hyd. c. cret. or castor-oil, within a few days. 
But in other cases it is due to some congenital malformation, 
some syphilitic thickening of the ducts, or to some inflam- 
matory or phlebitic affection of pyaemic origin, which has 
started in the umbilical sore. Such affections almost inevi- 
tably and very quickly cause death ; but cases are on record 
in which children have lived for some weeks, or even 
months, with such serious malformations as an absent com- 
mon duct.* Death usually results from hemorrhage from 
the umbilicus or from a more gradual wasting and exhaus- 
tion. Diseases of this kind hardly admit of treatment. 

Jaundice in older children is usually a temporary thing, 
and is thought to be due to catarrh of the ducts. The 
jaundice is not usually very deep, and a few days sees the 
end of it. Some mild laxative, such as the compound 
decoction of aloes, a little licorice powder, syrup of rhubarb, 
or fluid magnesia, is the only remedy that is requisite, if 
the diet be restricted. But in a case of jaundice, where the 
child has fever or vomiting, it is wefl to remember that 
icterus sometimes follows suppuration in the branches of 
the portal vein (pylephlebitis) or masked disease about the 
caecum, or elsewhere, and that such other things, as acute 
yellow atrophy, enlargement of the mesenteric and lumbar 
glands, etc., may exist, and give rise to the symptoms. I 
have also several times seen acute tuberculosis give rise to 
considerable enlargement of the liver and moderate jaundice. 

Of hydatid disease, lardaceous disease, and fatty degene- 
ration^ nothing need be said here, for they present no 

* Dr. F. B. Nunneley records the case of a child who lived nearly seven 
months wilh congenital obliteration of the hepatic ducts : " Trans. Path. Soc. 
London," vol. XXIII, p. 152. 

f For an analysis of these conditions, see " Diseases of the Digestive Organs 
in Infancy and Childhood." — Starr. 

15 



174 DISEASES OF CHILDREN. 

special peculiarities in childhood ; nor of cancer (sarcoma) 
of the liver need more be said than that when it occurs, 
which is very rarely, the growth is usually soft, lobulated, 
and very rapid in its spread. It is far less common than 
sarcoma of the kidney. I have seen five of the latter to 
one of the former. 

The albuminoid disease of rickets will receive sufficient 
notice in the article on rickets. 

Tubercular Disease requires mention, because it may 
cause considerable enlargement of the liver, which, except 
for this knowledge, may prove inexplicable, or more proba- 
bly be attributed to quite a wrong cause. There is usually 
some jaundice in these cases. The disease in the lung may 
be quite latent till toward the close. The liver may show 
either of two appearances, or the two more or less com- 
bined. There may be yellow caseous softening masses 
spread through the liver, which are tubercular growths 
around the smaller bile ducts ; or else there is an extensive 
miliary tuberculosis of the organ, in which the texture is 
irregularly stuffed with the lymphoid tissue; some parts 
being congested and some fatty ; and the tout ensemble show- 
ing a large mottled, sometimes nutmeg-like appearance. 

Cirrhosis of the Liver is found in all respects like that 
of adults, even to the wrinkled, blase appearance of the face, 
with its well-known congestion of the small vessels of the 
cheeks. Its chief interest, perhaps, centres round the dis- 
cussion of its cause ; some having contended that in chil- 
dren it is not due to alcohol, and that some additional light 
is thus thrown upon the pathology of the disease in adults. 
There is no space here to be more than dogmatic, and it is 
sufficient to say that even in children some of the recorded 
cases have been due to alcoholism, and that in others, there 
has been no sufficient disproof of the possibility of such an 
exciting cause. As Gerhardt says, alcoholism in childhood 



DISEASES OF THE LIVER. 175 

is very difficult to prove. It is probable, however, that it 
is not by any means the sole cause of infantile cirrhosis, 
though what the other causes may be we at present know 
but little. It is not unlikely, however, that some cases may 
be explained by congenital syphilis, and others by changes, 
either congenital or commencing in early infancy, of a very 
chronic hyperplastic character around the ducts or veins. 
Intermittent fever and phthisis have also been found asso- 
ciated with it, and Dr. Pepper has reported a case in a child 
of eight years, in which it followed measles, catarrhal jaun- 
dice coming on during the exanthem. Cirrhosis of the 
liver is not a disease of early infancy ; a very few cases are 
on record in the new-born, but it is most common at the 
age of about seven or eight years ; it must be admitted that 
in the majority of cases the early history and onset have 
been exceedingly obscure. 

Morbid Anatomy. — In most of the cases the liver has 
been markedly granular and fibrous throughout; in some 
there has been extensive scarring, and consequent distor- 
tion, so as to give some color to the idea that syphilis has 
been at work. The histological changes have been mostly 
those attending the more chronic forms of the disease — that 
is to say, more fibrous than cellular. The earlier stages of 
enlargement of the viscus and new growth of cell elements 
have been described as in adults, and no doubt occur, but 
are likely to escape notice until the onset of ascites. 

The symptoms are for the most part a precise reproduction 
of those which occur in adults; perhaps it maybe said that 
splenic enlargement is more constant, and that diarrhoea is 
a more prominent symptom. Ascites has been extensive 
without much jaundice in all the cases the author has seen. 

The prognosis and treatment require no special mention. 

Syphilitic Hepatitis may be of three kinds. The liver 
may be subject to acute swelling, which, without showing 



I76 DISEASES OF CHILDREN. 

very much change to the naked eye, is associated with a 
diffused cell-growth throughout the organ, either scattered 
or gathered into miliary gummata; there may be a localized 
gummatous change here and there, as in adults; or, as in a 
case recorded by Dr. Barlow, scars of retrocedent gummata; 
or there may be a nodular or streaky affection of the septa 
— a peri-pylephlebitis syphilitica. 

In any case there may be adhesions about the capsule of 
the organ. 

All these changes are chiefly met with in the full-time or 
premature foetus, or in the first few weeks of life. Cicatrices 
or a diffused swelling appear to be the commoner forms of 
the disease. Dr. Wilks has recorded a case of the latter 
kind in an infant of four weeks old,* and Gubler, V. Baeren- 
sprung, and Wagner have gone carefully into the subject, 
but there are not many complete cases on record. The 
liver is enlarged, hard, and elastic, creaking under the scalpel, 
and torn with difficulty; it is often pale or mottled. 

In the few cases that I have seen, the microscopical char- 
acters of the disease have been remarkable for the extreme 
degree of cell-growth that has occurred, so much so that it 
has been difficult, if not impossible, to give an opinion upon 
the mode of invasion which the disease has pursued. The 
hepatic cells were inextricably mingled with those of the 
syphilitic growth, nearly all trace of the natural structure 
having been lost. This condition is not unimportant in 
regard to the subsequent occurrence of cirrhosis. It would 
seem to be one that, if not fatal in itself, is preeminently 
likely to produce a subsequent cirrhosis; and no doubt it 
is one of the facts upon which those may rest who consider 
that the cirrhosis of older children is in some cases due to 
syphilis. The spleen is often enlarged as well as the liver. 

* " Trans. Path. Soc. London," vol. XVII, p. 167. 



DISEASES OF THE LIVER. 177 

Symptoms. — The liver may be much enlarged and hard. 
There may be ascites and some amount of jaundice. The 
following case will illustrate these points : — 

A male infant, aged two months, was brought to the hos- 
pital for enlargement of the abdomen, which was much dis- 
tended and shiny, and the veins in the wall large and full. 
The abdomen had been gradually enlarging since a fort- 
night after birth. The liver was much enlarged and bossy, 
extending halfway to the umbilicus, its edges being sharp 
and well-defined. The spleen was very large also. 

The child was much wasted and pale, its mouth wrinkled, 
but there was no other trace of syphilitic eruption in any 
part of the body. 

It was treated by a grain of hyd. c. cret. night and morn- 
ing, and soon improved, gaining flesh rapidly, and the liver 
and spleen, the former particularly, diminishing much in 
size. This child was under treatment, on and off, for four 
years for various ailments, an attack of snuffles among 
them, and remained quite well as regards its liver and spleen. 
During this time another infant was born, and this also was 
under treatment for well-marked congenital syphilis. 

Diagnosis. — -There can hardly be any mistake. Setting 
aside the fact that enlargement of the liver and spleen at 
this early age are rare, except in syphilis, there are the 
recognized symptoms in the parent and in the child itself, 
which should in most cases clear up any doubt. 

Prognosis. — Steiner remarks that these cases are usually 
fatal; but such has not been the author's experience. Judg- 
ing from some eight or ten cases they seem to be remarka- 
bly amenable to mercurial treatment, as was the case just 
detailed. Under mercurials the liver will rapidly diminish; 
the spleen is, as already stated, less easily acted upon. 

Treatment. — A grain of hyd. c. cret. may be given every 
night, or night and morning, for two or three weeks, or 



178 DISEASES OF CHILDREN. 

longer if necessary, and some syrup of the iodide of iron 
may be added later. 

Functional Disease. — Far more frequent than cases of 
organic disease are instances of what is popularly termed 
sluggish liver — children whose bowels are habitually con- 
fined and the evacuations pale and deficient in bile. Thus, 
in effect, says Dr. West,* who has described these cases so 
concisely that it seems unadvisable to do otherwise than 
copy him: "Without being positively ill," he says, "chil- 
dren thus affected are usually sallow and look out of 
health ; their appetite is variable, and their tongue never 
quite clean." As related to these, Dr. West alludes to the 
cases of older children who, with good health and regular 
habits, yet every few weeks or months have a bilious attack 
with severe headache. As to the nature of these last cases 
there may well be a doubt, many would be inclined to con- 
sider them less as hepatic diseases than as illustrations of 
megrim or some allied disorder. The habits are irregular, 
the excreta pale, the tongue furred, and the breath foul, and 
attention to the bowels and the functions of the liver mends 
matters considerably. 

Treatment. — In this condition euonymin is a good remedy 
— a quarter to half grain with some white sugar twice or 
three times a day. If the bowels do not act, the euonymin 
may be given with some cascara sagrada, or the compound 
decoction of aloes, or sulphate of magnesium, with the 
compound infusion of roses. Nux vomica, hydrochloric 
and phosphoric acid are also useful in these cases. 

Lithaemia. — Other cases, which may also be called he- 
patic, give evidence of disturbances which are chiefly 
urinary. A child perhaps of three or four years old be- 
comes fretful. It may seem pretty well, but perhaps sud- 

* " Diseases of Children," 5th edit., p. 607. 



DISEASES OF THE LIVER. 1 79 

ienly, and frequently, will cry, quickly recovering itself 
md resuming its play. With this disturbed mental equi- 
ibrium there is frequent micturition, and the urine deposits 
he red sand of uric acid or a thick pink sediment of urates, 
rhis is the condition which in older people, and with more 
variety of symptoms, Murchison denominated lithaemia. It 
s often associated with irregularity of bowels. 

Treatment. — The meat in the child's diet should be tem- 
>orarily reduced or stopped. Fish may replace it, or the 
:hild be confined to milk and egg diet for a few days, and 
Lt the same time some effervescing citrate of magnesium 
nay be given twice or three times a day. 

These are also cases which are benefited by euonymin or 
he decoctum aloes co., one or two teaspoonfuls three times 
i day. 

Peritonitis sometimes occurs in the foetus, when it is due 
sither to syphilis or to septic infection from the mother, 
jerhardt states that many cases of congenital stenosis of the 
ntestine are dependent upon peritonitis. 

In the newly born it is also septic, usually suppurative, 
ind occurs in association with unhealthy inflammation at 
he umbilicus. It is accompanied by high fever, vomiting, 
nd distention of the abdomen, and in most cases the 
latency of the infundibuliform process of the peritoneum 
Hows of the escape of fluid into the tunica vaginalis. In 
tine cases out of ten it is the right tunica that fills, and 
edema of the scrotum often exists at the same time(Sanne, 
rom Quinquad). Again, it appears sometimes to be due to 
yphilis (West), associated with enlargement of the liver 
nd spleen — which rapidly disappears under a mercurial 
reatment — and Dr. Goodhart has seen extreme ascites from 
his cause in an infant a few months old. 

In older children the remark holds good for peritonitis as 
:>r ascites, that most authors are inclined in many cases to 



l8o DISEASES OF CHILDREN. 

attribute to chill an important share in its production. Some 
talk, also, of a rheumatic peritonitis ; and cases occur in 
which the question of a rheumatic origin arises. 

Peritonitis may also occur after scarlatina or other fevers, 
when it is prone to be of a suppurative kind. It is more 
often secondary than primary ; that is to say, it is usually 
an extension from some disease of the viscera which the 
serous membrane envelops, or of parts in near proximity. 
Thus, it is not uncommon to find a local inflammation of the 
peritoneum which has extended from the neighboring pleura. 
It may occur also as the result of injury; it is not uncom- 
mon in boys and youths after falls, blows, or excessive mus- 
cular exertion, and in adolescent females the changes that 
take place in the pelvic viscera during the establishment of 
the menstrual function may light it up. It is sometimes 
due to rupture either of spleen or liver ; in rare cases it may 
be due to ulceration of the stomach, or gastritis. Sometimes 
again it is caused by the ulceration of typhoid fever ; and — 
of more importance, because more frequent than any of 
these causes — ulceration of the caecal appendix must also 
be mentioned. 

The symptoms are pain, fever, vomiting, and constipation. 
Their severity varies with the extent of the inflammation, 
the nature of exudation, and the acuteness of the course. 
The attack begins with rigor and vomiting of yellow or 
greenish mucus ; then there is local or general abdominal 
pain, which is lancinating in character and increased by pal- 
pation and by the acts of coughing, vomiting, and deep 
breathing. This symptom continues almost to the close of 
the disease. The face is pale and anxious, the decubitus 
immovably dorsal with the knees drawn up, and the abdom- 
inal respiratory movements cease. The belly is distended, 
dull to percussion, and the presence of fluid is shown by 
fluctuation, that of fibrinous exudation, by friction sounds. 



DISEASES OF THE PERITONEUM. l8l 

There is loss of appetite and urgent thirst; the tongue is 
dry and coated, and there is nausea, vomiting, hiccough, 
and constipation. The temperature is elevated, the pulse 
frequent and wiry, the respiration superficial, retarded, and 
superior-costal in type, and the urine often suppressed. In 
infants there may be convulsions ; in older children delirium. 

Should the disease become chronic the pain lessens and 
is more paroxysmal in character ; the fever is remittent, 
with evening exacerbations. Constipation alternates with 
diarrhoea; there is great emaciation, and death occurs from 
exhaustion. 

The diagnosis is often difficult; ileus, internal strangula- 
tion of any kind, and some of the more acute forms of 
enteritis, will produce similar symptoms. 

The prognosis will depend upon the severity of the symp- 
toms. The more the vomiting, distention of abdomen, pain, 
rapidity, and wiriness of the pulse, so much the worse the 
case, as a rule. 

Treatment. — Opium must be given freely by the mouth, 
warm poultices applied to the stomach, and the patient fed 
upon the blandest diet, and very little of it. The child may 
suck ice, and take milk and water, strong beef-tea, etc., by 
the spoonful. If necessary, nutrient enemata may be given, 
provided that they are retained. 

The method of treating peritonitis through purgation by 
salines has lately occupied considerable attention, but it is 
very questionable whether it is applicable in the case of 
children. 

Typhlo-Peritonitis. — This subject has been purposely 
reserved for consideration as a disease of the peritoneum, 
because the student is apt to think much of the ulceration 
and less of the peritonitis. It is common to hear the disease 
talked of as perityphlitis, with some idea of disease outside 
the peritoneum in the sub-peritoneal tissue. But the whole 
16 



1 82 DISEASES OF CHILDREN. 

importance of the affection lies in the fact that it is always 
a localized peritonitis, and not uncommonly a severe inflam- 
mation. A halting opinion on this point is fatal. An 
aperient given to drive on a scybalous accumulation has 
over and over again led to the death of the patient by in- 
terfering with new-formed adhesions, and thus giving rise 
to a general peritonitis and one which is apt to be suppu- 
rative. 

Causes. — The disease is most often due to impaction of a 
small scybalous concretion in the appendix caeci, but bodies 
of many kinds may pass into this part of the bowel and set 
up ulceration. The disease, moreover, not rarely occurs in 
tubercular subjects. It is an interesting question why the 
inflammation of the csecal appendix should be more common 
in young than in older patients. That it is so, there can be 
no doubt. Several things may in part explain this. In the 
first place, it seems often to occur in such subjects as give 
indications of delicacy. The greater heterogeneity of diet 
in young people must also be taken into account, and also, 
too, the more active intestinal action, which is characteristic 
of the time of life. Abnormal position of the appendix is 
also an important element in the causation. This results 
from its length and the attachment of its mesentery. Pos- 
sibly, therefore, small scybalous masses are more prone to 
enter the vermiform appendix in young people, and, if the 
subject be scrofulous or tubercular, to start an insidious 
inflammation and ulceration. It not uncommonly comes 
on after prolonged or excessive exertion. 

Symptoms are those of peritonitis, but it is a disease which 
varies much. It is often quite insidious in its onset, stomach- 
ache and irregularity of the bowels being the only complaints 
perhaps for several weeks. If it be more acute, there may 
be vomiting and constipation, with thickening in the region 
of the caecum, and in the worst cases it may be associated 



DISEASES OF THE PERITONEUM. 1 83 

with such severe febrile disturbance as to be mistaken for 
typhoid fever. 

The peritoneum is very treacherous in its reference of 
pain to particular spots. It is not uncommon for disease in 
one spot to cause pain in quite another, and for this reason, 
typhlo-peritonitis is likely to be overlooked. Therefore 
any griping abdominal pain of frequent recurrence should 
demand a careful examination by palpation of the abdomen, 
and one may hope to find some fullness, ill- defined thicken- 
ing, or definite induration to confirm the diagnosis if the 
disease be present. 

The affections of the caecum and appendix occur so fre- 
quently and are of such importance that before leaving this 
branch of our subject, it seems to the editor to be judicious 
to study them a little more in detail. 

a. Fecal distention of the caecum without inflammation 
of its coats, gives rise to constipation, vomiting, and a 
doughy, slightly sensitive tumor in the right iliac region. 
If the accumulation be excessive, it may, by pressure, pro- 
duce numbness and cedema of the right leg, retraction of 
the right testicle, and even some change in the secretion of 
urine. 

b. Inflammation of the csecal mucous membrane may 
be acute or chronic. When acute there is moderate fever, 
pain, and tenderness in the right iliac region, and diarrhoea 
with mucous, ill-smelling evacuations. If chronic, the 
patient becomes pale and emaciated, the tongue is coated, 
the appetite impaired, the bowels are irregular, and the 
stools are apt to contain mucus and a small quantity of 
dark-colored blood. There is pain in the abdomen, and 
the caecal region is often full and tender to the touch. 
There is no fever. In these cases surrounding parts may 
become involved in the inflammation, or an attack of true 
typhlitis may supervene. 



184 DISEASES OF CHILDREN. 

c. Inflammation of all the coats of the caecum and 
appendix or Typhlitis is attended by pain in the right 
iliac region, which is sudden in its onset and accompanied 
by marked tenderness to pressure. The patient lies on the 
back, somewhat inclined toward the right side, while the 
right thigh is flexed on the abdomen and any attempt to 
straighten it causes great suffering. The right iliac region 
is full, the abdominal wall in this position is tense, and 
when there is a large tumor there may also be numbness 
and oedema of the right leg and retraction of the testicle 
on the same side. There is usually obstinate constipation, 
occasional vomiting, fever, quickened pulse, anorexia, 
increased thirst, and a coated tongue. 

Should the inflammation be confined to the appendix 
there is less fullness of the caecal region, the pain is more in- 
tense, and no relief follows a free evacuation from the bowels, 
a result to be expected when the caecum is chiefly involved. 

When properly managed attacks of typhlitis should ter- 
minate in from three to five days ; sometimes, however, 
they last for twelve days, or in severe cases several weeks 
may elapse before all the symptoms have passed away. 
Tenderness to pressure is the most obstinate symptom, and 
until it has disappeared entirely the disease cannot be said 
to be cured. There is also a considerable tendency to 
recurrence. 

d. Perforative Ulceration of the caecum and appendix 
gives rise either to a general peritonitis or to a localized 
peritoneal inflammation denominated perityphlitis, or, in 
other words, " typklo-peritonitis" Should the perforation 
occur in such a position that fecal matter mingled with 
inflammatory products enters the peri-caecal tissue, a fecal 
abscess is formed. The patient passes into a hectic condi- 
tion, with rigors or even marked chills, followed by profuse 
sweating, a dry brown tongue, colliquative diarrhoea, rapid 



DISEASES OF THE PERITONEUM. 1 85 

feeble pulse, prostration and rapid emaciation. As the ab- 
scess approaches the surface the skin becomes dark-colored 
and doughy ; on palpation there is distinct emphysematous 
crepitation, and on incision fetid gas and grumous matter 
escape. 

Perforation of the appendix usually produces general 
peritonitis. 

When the caecum is perforated without the production of 
general peritonitis (which is almost always fatal), a favorable 
result may be looked for in a large number of instances. 
Of the cases of fecal abscess, those reopening into the intes- 
tinal canal are most apt to get well, while of those pointing 
externally about one-half recover.* If the appendix be 
perforated death almost uniformly results. 

Diagnosis. — In the absence of much local pain or swell- 
ing, and in the presence of general fullness of the abdomen 
and symptoms of blood poisoning, typhlo-peritonitis may 
be mistaken for typhoid fever. Dr. Goodhart has seen a child 
suffering from bright jaundice and fever where disease of the 
appendix caeci could only be surmised as being the most 
likely cause (by means of hepatic abscess) of the jaundice 
that existed. Local symptoms were quite in abeyance. 

Sometimes the local disease gives rise to an abscess 
which burrows in one direction or another, and which sub- 
sequently makes its appearance in some other part of the 
abdomen altogether. On the other hand, it may be diffi- 
cult to distinguish between scybala in the bowel and inflam- 
matory products around it ; but, whenever there is any 
doubt, one should always err on the side of caution, as an 
aperient treatment may be most disastrous. 

Prognosis. — If the symptoms are at all acute, the disease 
is one of much danger. The more the vomiting and the 

* Meigs & Pepper. 



1 86 DISEASES OF CHILDREN. 

constipation, the more the peritonitis, and, therefore, the 
more the risk. But it can hardly be taught too strongly 
that early recognition of the disease and appropriate treat- 
ment enhance considerably the chances of success. 

Treatment. — In all cases this is one of absolute rest. 
Opium and belladonna should be given internally; enemata 
used with caution to empty the rectum, and then to grad- 
ually empty the bowels from below, and poultices should 
be applied to the abdomen. In the more chronic cases the 
author believes some advantage is gained by applying a five 
per cent, solution of oleate of mercury to the abdominal 
wall over the thickening ; or the following combination of 
mercurial ointment, extract of belladonna, and glycerine : — 

Jjl . Ex. belladonnae, 

Ungt. hydrargyri, aa ^j 

Glycerinae, fjj. M. 

SiG. — Paint over the abdomen morning and evening. 

The diet is similar to that advised for peritonitis ; iced 
milk and beef tea in the early stages of the inflammation, 
and later more varied and nutritious food. In critical cases 
the quantity of food given by the mouth must be very 
small, and possibly everything but ice withheld, nutrient 
enemata or suppositories being administered instead. 

Supposing that the disease becomes thoroughly localized, 
an abscess may form, and it is important to be aware of this 
and to be on the look-out for its occurrence. The parts 
must be very carefully handled, for fear of disturbing any 
adhesions ; but attempts should be made, from time to 
time, to ascertain whether there be any fluctuation or not. 
In such a case an early, antiseptic, opening of the abscess 
will add materially to the chances of the child's recovery. 

Care must be exercised for some time after any severe 
attack of this kind. The matting and adhesion of the parts 
is often considerable, and for long afterward there may be 



DISEASES OF THE PERITONEUM. 1 87 

pain on any active exertion ; there are not a few recorded 
cases where a want of caution has led to a recrudescence 
of the original malady — sometimes, unhappily, with a fatal 
result. 

It would not be well to leave the question of treatment 
without some more distinct allusion to the intervention of 
surgery. Peritonitis of all sorts is passing more and more 
into the hands of the surgeon, and several remarkable 
successes have of late been recorded in cases which might 
well have been deemed desperate. Regarded from the 
point of view of the physician, the subject stands thus : A 
number — it is difficult to say how many, but probably a 
large majority — of these cases, if treated judiciously, get 
perfectly well, and for such, an operation, however suc- 
cessful, might well be called meddlesome. In others the 
inflammatory process localizes itself, then, if the symptoms 
indicate no progress toward recovery, or are in any degree 
urgent, an exploratory incision is not only justifiable, but 
demanded. Next come those other cases already described, 
where the peritonitis is general, and in which the life of the 
child is balancing. Then it is that the experience of other 
cases, hardly better, that have struggled through; the incu- 
bus against anything of the nature of an operation which is 
of the very breath of the atmosphere of " home ;" the fear 
that a serious undertaking, such as opening the abdomen, 
may extinguish the last hope ; the doubt that must exist 
whether, if an operation be begun, any relief can be afforded, 
and similar considerations, make turmoil when we most 
need dispassionateness, and must needs make us ask whether 
in such cases we can ever cease to halt. We can be wise 
after the event and talk glibly of the advantages of early 
operation, but this is small help to us when the point aimed 
at is so to time our measures as to be neither too soon nor 
yet too late. No precise rules can be established ; these 



1 88 DISEASES OF CHILDREN. 

cases must remain full of anxiety, of doubt, and difficulty, 
and the man of courage and judgment will occasionally 
save a life by a timely and carefully-conducted operation. 
So far as advice can be given, it may be said that for a dry 
peritonitis probably no good will come of surgery. If any 
evidence can be obtained favoring the existence of pus 
or of serum — for the serum in these cases is irritant and 
noxious, and often as urgently calling for removal as pus — 
here, if the right moment can be seized, an incision, and 
such steps as may be necessary for cleansing the perito- 
neum, will, at any rate, sometimes prove successful. 

Peritoneal Abscess, or localized suppurative peritonitis, 
occurs occasionally, and generally after scarlatina, or some 
other debilitating disease. The disease which has just been 
discussed might not unnaturally be supposed to occasionally 
produce it. 

In three cases that occurred in Dr. Goodhart's practice, 
one was attributed to typhoid fever, one followed scarlatina 
after some considerable interval, and in one no cause could 
be assigned. In one of these cases the abscess had already 
opened spontaneously at the umbilicus, and there was a 
free discharge of thin pus. In the other two there was a 
diffused, fluctuating swelling, dull on percussion, in the 
lower part of the abdomen. In one case there was severe 
constitutional disturbance ; in another, slight fever ; in the 
other, which had opened spontaneously, none. In all there 
was some abdominal pain. One of these cases was sent to 
the hospital for retention of urine, and the position of the 
swelling in the median line and lower part of the abdomen 
much resembled that of a distended bladder or miniature 
pregnancy. 

Diagnosis. — A positive opinion can hardly be arrived at 
without exploration. This was done by means of a hypo- 
dermic syringe in two of the cases alluded to. 



DISEASES OF THE PERITONEUM. 1 89 

Treatment. — As soon as there is an evident collection of 
fluid which does not disappear by remedies — or should 
there be severity of the constitutional disturbances or other 
reasons requiring interference — an exploring syringe should 
be passed through the abdominal wall into the cyst, and, 
pus being found, a free incision should be made at that part 
which seems most suitable for the particular case. The 
contents of these abscesses are usually very fetid ; never- 
theless, washing out the cavity need not be adopted imme- 
diately. It will be sufficient to allow free drainage by means 
of a drainage-tube; taking care, by the application of iodo- 
form, marine tow, or carbolic gauze, to keep the external 
parts as sweet as possible. Very foul cavities treated in this 
way have a good chance of becoming quite inoffensive 
within a few days, and, as with empyemas, all interference 
with the walls of the cavity is to be avoided if possible. 
This, however, is a matter upon which some difference of 
opinion exists. The wound must be dressed as often as 
necessary to remove the discharge, and, as this diminishes, 
the drainage-tube may be removed. The child must, of 
course, be kept in bed for some days, and fed upon the 
lightest diet, such as milk, beef-tea, blanc-mange, etc. In 
critical cases it will be necessary to confine the patient to 
beef juice and similar articles, or to resort for a time to 
rectal alimentation. A little Dover's powder may probably 
be necessary to relieve the pain for some few days. The 
bowels can be relieved by enemata, and subsequently qui- 
nine, iron, and phosphoric acid will form a good tonic and 
help on recovery. 

Ascites is not a very common occurrence in childhood. 
Apart from such obvious causes as diseases of the lungs, 
heart, kidneys, or liver, it may be due to tubercular peri- 
tonitis, or some tubercular affection of the abdominal glands. 
Yet it would appear that a simple dropsy of the peritoneum 



I9O DISEASES OF CHILDREN. 

is of more frequent occurrence in children than in adults. 
Ascites is sometimes due to cirrhosis and other enlarge- 
ments of the liver, such as syphilitic or lardaceous disease ; 
it may also be associated with enlargement of the spleen, or 
abdominal tumors, or with obstruction of the vena cava from 
enlargement of the retro-peritoneal glands. As regards 
what has been called simple dropsy, very little is known 
about it, save the fact that ascites sometimes comes and goes 
without any definite cause. Some think that exposure will 
lead to it ; others that it may be due to anaemia or malarial 
poisoning. 

Should the quantity of fluid be small, the symptoms are 
very indefinite. If large, the abdominal wall is arched for- 
ward, and fluctuation is distinct. When the patient lies 
upon his back, percussion is tympanitic over the upper 
and anterior parts of the belly, where the intestines float 
free, but dull elsewhere ; a change in position alters the 
relation of the areas of dullness and tympany. The super- 
ficial veins are prominent, and the umbilicus may protrude. 
Respiration is embarrassed, the bowels are constipated or 
relaxed ; there is painful micturition, and the urine is often 
diminished in quantity, and contains albumen, blood, and 
tube-casts. 

Diagnosis. — Ovarian tumors rarely occur in childhood ; 
nevertheless, such sometimes happen, and a tumor of this 
nature may easily be mistaken. Hydronephrosis might also 
lead to mistake, and also large hydatid tumors in the liver 
or elsewhere. But perhaps the most likely to resemble it 
is the large pendulous abdomen seen in some rachitic chil- 
dren or with long-standing mucous disease. It is remark- 
ably large in some of these cases, and, when the child is 
erect, prominent, but lying in bed, and the parts being flac- 
cid, much of the protuberance subsides, to be replaced by 
lateral bulgings, like the belly of a frog. A perfect undula- 



DISEASES OF THE PERITONEUM. I9I 

tion may not be obtained from an abdomen of this sort 
unless care be taken to steady the flaccid walls. The note 
on percussion is often somewhat dull, and, unless the flanks 
be carefully examined in different positions, a mistake is by 
no means difficult, even with a practiced hand. 

Treatment. — This must depend upon the cause ; but, per- 
haps, the most important points to bear in mind are the 
necessity of reducing the quantity of fluids given to the 
child, and of giving iron in cases in which no cause can be 
discovered. The iron may be given as the iodide or the 
saccharated carbonate of iron, and diuretics (in addition to 
the copious use of water) can be given as well. The resin 
of copaiba seems to be exceptionally useful in adults in cases 
where there is a healthy kidney ; but Dr. Goodhart has 
not tried it much in children, although there is no reason 
save the taste against its use. Digitalis and squill can be 
made more palatable, and a course of hydragogue cathartics 
often gives most satisfactory results. A local application of 
oleate of mercury or mercurial ointment to the abdomen is 
of value. 

If the fluid does not diminish after a good trial, paracen- 
tesis should be performed. This operation is not only pal- 
liative, but it is a remedial agent of great value. For this 
purpose a very fine canula, such as that called a Southey's 
tube, should be employed. A drainage-tube is attached to 
this, the canula is left in, and the fluid allowed to drain 
away for some eight or ten hours. The abdomen should 
be carefully bandaged the while, and continuous pressure 
must be kept up afterward. The fluid is not all removed 
by this means, but enough is withdrawn to relieve pressure 
and allow of absorption. Moreover, the operation of para- 
centesis on this plan is so slight that the child is hardly 
frightened by it, and it can be repeated when necessary. 



PART II. 
ACUTE INFECTIOUS DISEASES. 



I. Measles (Morbilli). — Incubation. — By this is meant 
the time between the actual introduction of the poison and 
the appearance of the first symptom of illness. 

In regard to this point Dr. Goodhart writes, in com- 
mencing the subject of contagious diseases : " I should 
wish to say once for all, as regards periods of incubation, 
that it seems to me futile to attempt, as is often done, 
to fix them too precisely; it is quite certain, from the 
material already collected, that the period varies for most of 
the exanthemata, and sometimes to a considerable degree. 
In measles the period is ten days usually, but in the case 
of a baby seen by Dr. Marshall, incubation was as long as 
three weeks. In a boy and girl lately in the Evelina Hos- 
pital, five and three years old respectively, it appeared to be 
at least twelve days in the one .case and sixteen in the other : 
A child fell ill with the measles in one of the small wards of 
the hospital, and was at once removed to the fever ward. 
Sixteen days later the boy had the rash upon him, and 
four days later the girl. These two were in adjacent beds." 

However, this period, in the disease in question, has been 
established (i) by experiment, measles having been intro- 
duced by inoculation in Edinburgh, Italy, and Germany; 
(2) by the careful observation of outbreaks of the disease in 
what may be called virgin soil, such as that in the Faroe 

193 



194 DISEASES OF CHILDREN. 

Isles, by Panum ; (3) from the records of actual practice as 
it occurs in our own climate. From all these sources it 
would appear that, though liable to modification within 
limits of three or four days either way, the incubation 
period centres around ten days. 

For instance, E. and F., of eight and ten, were at school 
from the 10th or nth to the 19th of the month, with a child 
who then sickened with what was subsequently found to be 
measles. The child sneezed so much on the 19th that the 
mistress particularly noticed her. And on the 25th E. began 
to be poorly ; on the 30th a punctiform red rash appeared 
on the palate, and she left school for giddiness ; and on the 
31st the eruption appeared on the face, and quickly spread 
downward to trunk and legs. F. was sleepy, and had 
headache on the 30th ; on the 31st the evening temperature 
rose to 100.4 , and the symptoms of catarrh increased; on 
the 1st, the punctiform eruption appeared, and on the 3d, 
the rash was noticed on the skin. 

These cases also illustrate the impossibility that often 
exists of exactly fixing the date of the introduction of the 
poison. Both children were at school, E. eleven days, F. 
eleven or twelve days after the source of infection left, but 
it is not improbable that the house or room in which they 
were, was infected, and that the actual reception of the 
poison by F. was of later date than that by E. 4 

Prodromal Stage. — This is characterized by what is com- 
monly called a cold, and lasts about four days. The child 
is drowsy, sometimes remarkably so, and thus may give an 
early suggestion of what is coming ; it has headache. Then 
come redness of the eyes and lids, and running from the 
nose. Next there is a dry cough having a croupy character 
sometimes, and the evening temperature begins to rise. The 
coryzal aspect — if the child be poorly, which generally means 
feverish — is very suspicious. The palate should now be 



MEASLES. 195 

carefully examined, and not infrequently the roof of the 
mouth behind the hard palate may be seen covered with a 
sharply-defined red blush, with a number of minute red 
papules upon it. Described by various independent ob- 
servers, the value of this blush is an initial symptom pre- 
ceding the eruption by some hours, is indorsed by Meigs 
and Pepper, Henoch, and others, and Dr. Goodhart has 
seen it well marked in some cases. Barthez and Rilliet do 
not, however, attach any value to it. The American editor 
believes that the punctiform rash and red blush are almost 
uniformly present, and precede the cutaneous eruption by 
almost twenty-four hours. Other symptoms are occasional 
only, and therefore of little value ; chief among these are 
epistaxis and vomiting; in young children this stage is at 
times attended by severe capillary bronchitis. 

Eruptive Stage. — The eruption appears about fourteen 
days from the date of infection, or four from the first signs 
of illness. It is first seen about the ears, temples, and face, 
in the form of small, dull, red papules tending to cluster 
more or less in crescentic lines, although not usually 
arranged with any great regularity. In favorable cases its 
course is now rapid ; within ten or twelve hours it will have 
spread to the trunk, and even to the legs, and within twenty- 
four the face will be more or less covered with dull red, 
raised, and often confluent, blotches which strangely alter, 
not to say disfigure the features. The face generally bears 
the brunt of the attack ; it is not usually so thick on the 
trunk, and still less on the legs. The temperature usually 
mounts, by evening rises and morning falls, for the four 
days preceding the outbreak of the eruption, and then falls 
again rapidly in twenty-four or forty-eight hours, when the 
rash begins to fade. In mild cases it is normal or subnormal 
by the third or fourth day from the first appearance of the 
rash. This is illustrated by the following : — 



\g6 



DISEASES OF CHILDREN. 



Case i 




-Boy of 15. 


4th day m 


T. 


IOI°| 


eruption 
appeared 


E. 


T. 


104.6 




5th day m. 


T. 


I02° 




E. 


T. 


102.2° 




6th day m. 


T. 


IOI° 




E. 


T. 


99 .6° 




7th day M. 


T. 


97. 7° 


etc. 



Case 2. — Girl. 
3d day M. T. normal. 

4 th day m.t. 102.30/ eru P tion 
I appeared. 

E. T. 103.8 
5th day M. T. 1 02. 4 

e. t. 102.3 
6th day m. t. 98 

e. T. 99.3 , etc. 





















Fig 


■ 3- 






















F. 
IO5 

I04° 

I0 3 ° 
102° 
IOI° 
IOO° 

99° 
98.4 

Day 

o/Dis. 


M E 


M E 


M E 


M E ; M E 


IVI E 


M E 


IVI E 


M E 


M E 




















































































































































































m 








































A 








































\ 
































t~[ 






^ 




































f 


\ 








































k 
































f\ 


/ 






\ 



































V 

* 






\ 




































\ 








































\ 








































\ 




















































































































































— J 










' 


























f 


_L 


































K 


j 




"7 


































\ 


/ 




rt 


































/ 


1/ 




XL 














V 




















/ 


\ 




it 














\ 






J 


1 












/ 


I 




x 














V 






J 


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A 




A- 


7 


\ 
































\ 




/ 




\ 


































t / 


' 




k, 










1 
























\ 








r_ 








/ 
























Y 








\ 








/ 
































; 







\ 








































si 
















1 
















I 


2 


3 


4 ! 5 


6 


7 


8 


9 


10 


Pulse. 


00 **■ 
QO o\ 


00 \o 

00 as 


88 


vo i 00 





22 


: ° M 


N O 


S 2 



TEMPERATURE CHART OF MEASLES. 



The above chart presents a very fair average of the 
temperature tracings and the pulse rate of a case of ordi- 



MEASLES. 197 

nary severity. The patient was a boy five years old, an 
inmate of the Children's Hospital, Philadelphia ; coryza 
appeared during an epidemic of measles on the day 
marked 1, the eruption on the evening of that marked 4, 
and was at its height during 5 and 6. After that there was 
a rapid decline to almost the normal point on 8, though 
complete lysis was delayed for forty-eight hours by a 
trifling secondary laryngeal catarrh. 

Regularity of temperature rise cannot be depended upon 
in the prodromal stage ; it may, with only slight disturb- 
ance previously, run up quickly at or just before the out- 
break of the eruption ; or the height of the fever may be 
reached before the eruption appears. If the temperature 
remains high after the fourth or fifth day from the appear- 
ance of the eruption, the lungs should be carefully examined 
and watched. Very commonly some broncho-pneumonia 
is the cause of this. 

The eruption soon fades, but leaves the skin somewhat 
marbled by reddish-brown stains for some days afterward, 
and, when the rash has been profuse, is often followed by 
slight branny desquamation, most visible about the face 
and neck. The pulse is full, soft, and considerably quick- 
ened during the height of the attack — 120 to 140 — and 
may even be intermittent for a few hours ; but it speedily 
recovers itself at the first approach of a crisis. The bron- 
chial affection is generally the most persistent part of mea- 
sles. The disease is ushered in by a dry cough, and more 
or less catarrh results from this, consequently a loose cough 
or one associated with an excess of secretion, may linger for 
some days. In many cases no more than this happens, the 
pulmonary parenchyma remaining healthy throughout, or 
at most showing no other abnormality than harsh breathing 
or an occasional rhonchus or rale. In severe cases the 
chest affection is paramount, and we then have to deal with 
17 



I98 DISEASES OF CHILDREN. 

a diffused broncho-pneumonia or capillary bronchitis, with 
perhaps a sluggishly appearing or retrocedent eruption, pal- 
lor of face, lividity of lips, dilating alae nasi, and high fever. 

Modifications. — It has been the custom to describe three 
or four varieties of measles, but it is enough to state that 
measles, like all other exanthems, is liable to vary. The 
typical disease is known by fever, a peculiar eruption, 
and a catarrhal inflammation of the respiratory passages. 
Common sense will tell any one that in very mild cases 
the catarrh may be absent or the eruption all but so. 
In bad cases, on the other hand, the eruption may become 
very dark-colored or even petechial, and the catarrh, 
which is a part of the natural history of the disease, be 
replaced or added to by a more or less severe broncho-pneu- 
monia. In such cases also, it hardly needs the saying, the 
eruption may be irregular in its progress, or fitful in its 
appearance, and the general indications from pulse, temper- 
ature, and nervous system, are likely to be grave in pro- 
portion. The condition, however, which is described by 
Barthez and Rilliet as rougeole anomale is worthy of distinct 
mention, because it calls attention under one term to many 
puzzling cases in which the eruption comes out later or in 
some lagging fashion, and in parts of the body where we 
should perhaps not expect it, such as on the abdomen or 
extremities. Measles may appear first on the buttocks, for 
example, where eruptions of all sorts are so common, and 
should the child have been ill for four or five days with acute 
pneumonia, the real disease might well pass unrecognized. 

Complications and Sequelce. — Of these by far the most 
important, because most frequent and most dangerous, are 
broncho-pneumonia and membranous laryngitis, or croup. 
Of others may be mentioned marasmus, diarrhoea, whoop- 
ing-cough, and, as late oncomers in unhealthy children, a 
tribe of glandular and other affections — discharge from the 



MEASLES. IO9 

ear, suppurating glands in the neck, caseating mediastinal 
glands, and general tuberculosis. Albuminuria is a rare 
sequela. Dr. Goodhart has seen it once in the second 
week. Broncho-pneumonia, being, in a measure, part of 
the natural history of the disease, is the most common and 
the most destructive to life. When it comes on suddenly, 
as it may do in young children, the eruption may be slight, 
but the temperature often rises in these cases to 105 or 
106 , the child becomes pallid or livid, and dies in a semi- 
collapsed state. Naturally there are all degrees of pulmo- 
nary affection between this the most extreme and the milder 
cases. 

Membranous laryngitis is another common outcome of 
measles. It may attack the child at any time; most usually 
within a week or ten days after the subsidence of the rash. 
It is probably epidemic in its occurrence — that is to say, is 
more prone to occur at special times than to attack all cases 
of measles indiscriminately. But from its gravity the pos- 
sibility of its occurrence should never be forgotten, particu- 
larly if laryngeal cough has been troublesome or persistent 
during the fever. 

Diarrhcea is another associate which may either usher in 
or follow the disease, and is described by Henoch as some- 
times being very profuse and dysenteric in character. It 
also is epidemic in manifestation. 

Marasmus may also be mentioned, for this reason that 
when very young children — a year to eighteen months or 
two years old — are attacked with measles, it may happen 
that the eruption comes out sluggishly, the fever persists, 
though not to any excessive degree — 102 to 103 — the 
tongue and mouth become dry and ulcerated or covered 
w r ith sordes, and rapid emaciation takes place. And this, 
without any pronounced broncho-pneumonia, croup, or 
other fatal accessory. 



200 DISEASES OF CHILDREN. 

Whooping-cough is generally spoken of as being espe- 
cially related to measles, and certainly the impression that 
is left upon the mind as the outcome of experience is, that 
the two affections often follow one upon the other. But 
when an appeal is made to statistics the association appears 
to be less common than anticipated. Of 305 cases of per- 
tussis noted by Dr. Goodhart, recent attacks of measles had 
only occurred in fourteen. There would appear to be some 
difference of opinion also as to the relation which the two 
diseases bear to one another. West speaks of measles as 
following the pertussis. Dr. Goodhart's experience is con- 
trary to this. In all of his fourteen cases the measles came 
first and the pertussis closely followed. For instance, a 
girl aged thirteen months, was well till six weeks before 
admission ; then came measles, and after fourteen days per- 
tussis. But the cough may follow within a day or two of 
the outbreak of the measles. When measles follows upon 
pertussis, the characteristics of the latter may temporarily 
disappear. What the real relation of the one to the other 
may be, can only be a matter of conjecture, but it is proba- 
ble that for measles, pertussis, membranous laryngitis, and 
varicella — all of which seem prone to combine — the pre- 
sence of any one lessens the resistance which a healthy 
body manifests to the infective power of the others. A 
child therefore witlj measles would be more susceptible to 
either of the others should it be epidemic at the time. 

Noma and necrosis of the nasal cartilages after measles 
have been recorded. The former is probably not uncom- 
mon. Jacobi speaks of it as common, and Dr. Lewis 
Marshall has seen many cases where noma pudendi has 
followed them. The American editor has met with several 
cases of noma, and one case of noma pudendi following 
closely upon measles ; ulcerative stomatitis is a very com- . 
mon sequel. As late results of measles there are many in- 



MEASLES. 20 1 

definite conditions of ill-health when the disease has been 
severe or neglected. It is certainly far from uncommon in 
the out-patient practice of a children's hospital to hear the 
tale that the child has never been well since the measles. 
And this in all sorts of affections — marasmus, glandular 
abscesses, skin affections, etc. It is, however, very difficult 
to arrive at facts, but it is quite certain that a very common 
result of measles is cheesy degeneration of the mediastinal 
glands, and a subsequent tuberculosis of the lungs. As will 
be stated elsewhere, one of the commonest forms of chest 
disease in childhood is a cheesy enlargement and softening 
of the mediastinal glands, and one or other form of lung 
disease supervening — generally a miliary tuberculosis, but 
not always. The history of many of these cases credits 
measles as the source, and nothing would seem to be more 
probable. Measles with its bronchitis or broncho-pneu- 
monia is followed, no doubt, in most cases with more or 
less inflammatory swelling of the corresponding lymph 
glands, which, becoming choked with inflammatory pro- 
ducts, undergo cheesy degeneration. Moreover, although 
less liable than scarlatina to any marked affection in the 
course of the fever, the glandular concatenate frequently 
undergo some slight enlargement and induration after 
measles, and no doubt slight changes originate then which, 
in unhealthy subjects, or from subsequent neglect, may run 
on into the chronic enlargements, cold abscesses, scrofulous 
ulcers, etc., which are so well known and so much dreaded. 
Etiology. — Measles exhausts the soil, and, as a rule, occurs 
only once. But in some cases a second attack or relapse 
follows the first after a short interval ; in others a true 
second infection must occur, the second attack being many 
years after the first. Sucklings appear to be less liable to 
.infection than older children, and when attacked often have 
the disease in a mild form. Measles is highly contagious 



202 DISEASES OF CHILDREN. 

in the catarrhal or preemptive, and also in the eruptive, 
stage. After this it would appear that the infective power 
becomes much less active and soon disappears. But there 
are cases on record of infection being conveyed in the third 
week after the outbreak of the eruption, and therefore the 
rule to be pursued is that if possible a month should be 
allowed to pass from the onset of the eruption before a 
child is again permitted to mix with healthy children. It 
is probable, however/'that very little risk indeed is run at 
the end of the third week, provided that the child is not 
surrounded by a more recently infected atmosphere, or by 
clothing improperly disinfected. Measles is chiefly con- 
veyed directly from the sick to the healthy ; but it can be, 
and is sometimes, carried through the medium of healthy 
persons by fomites. Such cases, however, usually show 
cause for copious infection — the medium being either a 
child coming from an infected house, or somebody who has 
recently been in contact with the sick. 

As regards isolation in a family, this is not usually prac- 
ticable in any strict fashion, but it should certainly be car- 
ried out for healthy children under four years of age, or 
for delicate children. In healthy children above that age, 
seeing that the disease so usually runs a favorable course, 
it is a question whether vigorous measures are worth 
attempting. Moreover, of isolation let it be remembered 
that to be effectual it must be put into practice early, not 
when the eruption appears, but at the very onset of the 
catarrhal stage, for this is the most dangerous time. This 
can best be done by the methodical use of the thermometer 
for every child that has been exposed to infection. When 
a child has had measles, it may return to school at the end 
of three weeks, if all desquamation and cough have ceased. 

Morbid Anatomy. — Nothing is yet known certainly as. 
regards the state of the blood. Quite recently a bacillus 



MEASLES. 203 

has been found in the urine of patients suffering from mea- 
sles, but at present, though everything points toward future 
advances in this direction, yet nothing can be stated with 
certainty. 

Drs. J. M. Keating and Henry F. Formad, in an epidemic 
of measles, occurring in the Children's Asylum of the Phila- 
delphia Hospital during the early part of 1882, found micro- 
cocci in large numbers in the malignant cases both during 
life and after death, but none in cases of mild type. They 
were found in the liquor sanguinis, and in the white blood- 
corpuscles, acting especially upon the latter. These obser- 
vations have since been confirmed in the editor's wards at 
the Children's Hospital. 

Drs. Braidwood and Vacher describe minute bodies ob- 
tained from the breath, and also in the skin, lungs, liver, 
etc., after death.* 

The microscopic appearances consist chiefly of more or 
less injection, perhaps even superficial erosion about the 
palate and epiglottis, sometimes also of the intestine ; and 
a diffused broncho-pneumonia. The last need not be de- 
scribed here, as it is treated in its place as one of the diseases 
of the chest. Atelectasis is not uncommon, and pleurisy is 
often associated with the pneumonia. Less common com- 
plications are, membranous laryngitis, diphtheria of pharynx 
or conjunctiva, keratitis and colitis. As a later condition 
Henoch describes a chronic broncho-pneumonia with dilated 
bronchial tubes and terminal abscesses in the lungs ; but it 
is not clear that this can be separated from the far more 
common condition of cheesy degeneration of the bronchial 
glands and lung with miliary tuberculosis superadded. 
Some authors describe an acute fatty degeneration of the 
liver, but this is a change which is not peculiar to measles. 

* " Trans. Path. Soc. of Lond.," vol. xxix, p. 422. 



204 DISEASES OF CHILDREN. 

In the previously-mentioned epidemic at the Philadelphia 
Hospital, death was found to be due to heart-clot, the forma- 
tion of which was supposed to depend upon the presence of 
large masses of micrococci in and about the white blood- 
corpuscles. 

Diagnosis. — The cardinal points in the diagnosis of mea- 
sles are the slow onset and the coryzal aspect. In scarla- 
tina, from which the difficulties chiefly emanate, the child 
is taken suddenly ill, often with vomiting, and within 
twenty-four hours the eruption appears. In measles there 
is less often vomiting, and the rash does not make its ap- 
pearance for four days. Of the eruption it is less easy to 
speak dogmatically — it is true that in a typical case the 
distinctions are plain — but there are many cases where from 
the eruption alone an opinion is impossible. 

For instance, a child seven months old was brought to 
the Evelina Hospital with what was clearly measles — coryza 
of two or three days and a characteristic swelling of the 
eyes. The eruption is thus described : there is a general 
red blush of the skin of the entire body, with additional 
raised small bright red papules, running sometimes in a 
crescentic pattern. The rash has some of the characters of 
scarlatina, some of measles. There will come to every one 
cases in which it is impossible to speak with certainty. In 
such it is necessary to take note of all the features of the 
case, and to form an opinion only after due deliberation — 
in the meantime taking all proper precautions. No dis- 
credit can attach to indecision when a decision is an impos- 
sibility ; and, on the contrary, nothing can be more dam- 
aging to the reputation than an ignominious retreat from a 
hasty diagnosis of "rose rash" or "German measles" before 
the developed and cold logic of facts. 

Treatment. — In the prodromal stage the child should be 
kept in one room in a regulated atmosphere of a tempera- 



MEASLES. 205 

ture of about 65 . As the cough becomes more trouble- 
some, some sedative, such as paregoric, may be given — 
twenty or thirty drops every three or four hours for a 
child of four or five years. The diet should consist of 
plenty of milk and water or barley-water, with any fari- 
naceous food that may be fancied, and bread and butter 
or toast. When the rash appears the child is to be kept 
in bed, and in an ordinary case very little more is re- 
quired. If the skin itches, as it sometimes will, the body 
may be oiled three or four times a day with carbolized oil 
(1 to 40). If the temperature rise to 103 , a warm bath 
98 to ioo° may be given as often as necessary. This acts 
as a good soporific in many cases. The cough is still to be 
treated by small doses of the compound tincture of camphor 
or some such expectorant as — 

R . Vini ipecacuanha 1 , f 3 ij 

Spt. aetheris nitros f 3 j 

Syrupi tolu, f^j 

Glycerines, f^ ss 

Aquae, q. s. ad f 5 iij. M. 

SlG. — A teaspoonful every two hours. 

If these means are not sufficient, nothing relieves the 
hoarse, hard cough of measles, which appears to be depend- 
ent upon an inflammatory condition of the rima glottidis, 
better than swabbing the fauces and throat with glycerine, 
or borax and glycerine, by means of a laryngeal brush. 

At the height of the eruption, the temperature not 
uncommonly runs up to 104 or 105 for a few hours, 
without any corresponding severity of the other symptoms. 
There is no need to interfere for a temporary disturbance 
of this sort, but for a persistently high temperature of 
twelve hours or more, some antipyretic should be given 
and bathing should be resorted to. Antipyretics are as yet 
only on trial, and the safest appear to be thalline sulphate 
18 



2C6 DISEASES OF CHILDREN. 

and antifebrin. Steffen speaks well of the former, but 
English experience seems, on the whole, to favor the latter. 
It may be given in doses of one to three grains or more. 
Its antipyretic action is pretty certain, but the extent of it 
variable. Therefore Dr. Goodhart thinks it advisable to 
begin with a small dose of one grain at any age from two 
to .six years. If the temperature falls afterward, wait and 
note the extent of the depression; if not, repeat the dose in 
an hour's time. The drug is usually given when the tem- 
perature rises to about 103 F., and is repeated as often as 
may be necessary to keep the pyrexia below that limit It 
is very insoluble, and may be given in powder in milk ; 
but it may be dissolved in rectified spirit, with the tincture 
of orange and water. 

As regards the bath, the first may be at a temperature of 
95 to 98 °. The temperature will often fall and sleep be 
produced by this means alone. If this fail to reduce the 
temperature, tepid or cold sponging may next be resorted 
to, or the chest and abdomen may be covered with an ice 
pack or by cold compresses. As a last resort the tepid or 
cold bath must be tried. The child should be undressed 
quickly, so as to be worried as little as possible, and then 
immersed in a bath of the temperature of 90 ; which then 
may be rapidly cooled by the addition of cold water to 8o°. 
Five or six minutes' immersion is usually sufficient. The 
child is then dried rapidly by a soft towel, and put to bed 
again between sheets. It is now to be watched carefully 
and the temperature recorded every two or three hours. 
The effect of the bath is sometimes very powerful, and the 
child remains livid-looking and collapsed for some time. 
In such cases small doses of brandy must be administered 
in warm milk at frequent intervals, and a hot bottle kept to 
the feet. Some go so far as to say that when the tempera- 
ture reaches 102° some one or other of these means are to 



MEASLES. 207 

be resorted to. Such a rule as this is meddlesome practice. 
There may be cases in which, with a temperature of 102 , 
the child is very ill, and the fever may be judged to be 
more than usually detrimental. For such, a bath, either 
tepid or cold, or cold sponging, may be recommended ; but 
for one such case, there are many others which run a per- 
fectly favorable course with a temperature even higher 
than this, and in which it may reasonably be asked in what 
way antipyretic applications could have bettered them. 
Each case must be judged upon its merits. 

Should the fever be very high, sulphate of quinia by the 
mouth or better by the rectum, in two to four grain supposi- 
tories every three or four hours, will frequently reduce the 
temperature and, should there be much restlessness, produce 
sleep. At the same time should symptoms of exhaustion 
or heart failure appear, tincture of digitalis or carbonate of 
ammonium with some alcoholic stimulant are indicated. 
The latter especially may be given freely when the case is 
malignant. 

As regards staying in bed, measles varies so much that 
no rule can be laid down. It is generally well to keep a 
child in bed for a couple of days after the temperature 
becomes normal, and to its room for a week longer. It 
should be kept indoors for three weeks or a month. The 
room occupied by a child with measles is to be kept well 
ventilated. In most cases the window may be allowed to 
be a little open at the top ; all draughts are to be avoided, 
and in obtaining fresh air the temperature of the room must 
not be allowed to fall. Darkening of the room is necessary 
when the eyes are much affected. 

Broncho-pneumonia, if it exist, must be treated as in 
other cases. If the child be feeble, a few drops of sal vola- 
tile or a grain of carbonate of ammonium may be given, 
and some liquid extract of liquorice ; or expectorants, such 



208 DISEASES OF CHILDREN. 

as squill, ipecacuanha, and compound tincture of camphor 
may be necessary. Counter-irritation may be applied by a 
mustard-leaf for a few minutes over the diseased part, fol- 
lowed by a warm fomentation or warm linseed-meal poul- 
tice at first, and then a cotton-wool jacket. The diarrhcea 
that sometimes accompanies measles is probably due to 
some catarrhal state of the gastro-intestinal mucous mem- 
brane, and the first thing to be attended to therefore is the 
quantity of food that is being taken. The milk may be too 
much, and thin broth or cream and whey, or egg albumen, 
may suit better for a few hours. In severe diarrhcea cold 
compresses are very useful. Several folds of linen are to 
be wrung out of cold water, put over the abdomen and 
covered with flannel, and changed every two or three hours. 
For medicines, thirty drops of brandy with some syrup and 
cinnamon water is a simple and an effectual remedy repeated 
every three or four hours. A teaspoonful of fluid magnesia 
is a good thing to commence with, given two or three times 
a day, and subsequently, if not successful, a few drops of 
dilute sulphuric acid may be given with a drop or so of 
opium. Dover's powder is also useful for such cases, and 
so also are the liquor bismuthi, the subnitrate of bismuth, 
and wine of coca. 

Membranous laryngitis will require a treatment such as 
that indicated in its special section ; but it may be said here 
that probably much may be done in measles to avert its 
onset if the throat and fauces be painted energetically with 
a solution of boracic acid, or borax and glycerine, every 
hour or two, whenever the cough becomes at all croupy in 
character. 

Other parts also require careful attention. The ophthal- 
mia which often succeeds to measles needs cleanliness and 
some mild antiseptic wash — permanganate of potassium 
being one of the best. The ear is prone to discharge after 



MEASLES. 209 

measles ; if so, it is at once to be taken in hand and treated 
carefully and regularly on antiseptic principles. It is to be 
gently syringed with a weak spirit lotion, a teaspoonful 
of spirits of wine to the half-tumbler of water, and carbolic 
oil (1-40), glycerine and borax, or the solution of boracic 
acid in glycerine, dropped in afterwards, and a little salicylic 
wool placed in the orifice. This is to be done three times 
a day, and every effort made to keep the part sweet. Some 
prefer what is called the dry method, and it is certainly very 
useful. It consists simply of blowing powdered boracic 
acid or iodoform, or any antiseptic that may be chosen, into 
the external auditory meatus by means of one of the small 
caoutchouc puffs made for the purpose. The great danger 
of aural discharge is its liability to decomposition, and de- 
composition of the discharge leads to extension of the 
inflammation to the bone which limits the tympanic cavity, 
and so to necrosis and its consequent evils. 

For some weeks after measles the health demands extra 
watchfulness. A salt-water bath should be given in the 
morning, and the clothing be always warm. Anaemia must 
be treated by iron and cod-liver oil. Any capriciousness of 
appetite should be guided, if possible, back to normal by 
the same means, or by the judicious administration of 
stimulants, and above all by change of air — a dry, bracing 
air — whether it be sea or inland, and plenty of it, is one 
of the best restoratives. If there be any tendency to 
enlargement of the glands, no doubt sea air is the 
better ; otherwise a farm-house life, with its freedom 
from restraint, its good milk and bread, its rough-and- 
tumble exercise on a farm-pony, is the best restorative 
in existence. 

2. Scarlatina. — Of all the diseases of childhood there is 
none which presents greater varieties of aspect than scar- 
latina — none which so often brings, with very short notice, 



210 DISEASES OF CHILDREN. 

unexpected deaths into a healthy household, or which more 
often selects for its victims the robust and healthy. Thus 
writes the late Dr. Hillier; and it would be difficult to put 
more shortly and more graphically the terrors of this scourge. 
Dr. Goodhart writes : " Some years ago, when taking charge 
of a practice in the country, I was called to a village some 
miles away to see a child who was very ill. I found a well- 
nourished girl of about five years old. She was pulseless, 
livid, and comatose, with an almost petechial scarlatinal 
eruption covering the skin. I was told that she had been 
quite well till the preceding afternoon. She had suddenly 
vomited while at Sunday-school, and came home ill. I saw 
her about eight p.m. the next day, and she died within three 
or four hours ; so that the duration of the disease from its 
outbreak to the death of the child was under thirty-six 
hours." 

Scarlatina is in great measure a disease of childhood, 
sixty-three per cent, of the deaths, according to Murchi- 
son, being under five years of age ; ninety per cent, under 
ten ; and ninety-five under fifteen years. The disease is not 
prone to attack children in the first year of life, and this is 
more markedly the case even than with measles ; but it may 
occur at any age, and cases are on record where infants 
have been born with the eruption upon them, and in which 
desquamation has occurred in due course. Meigs and 
Pepper have seen it perfectly well marked in an infant 
twenty-one days old. It is a disease which occurs in epi- 
demics, though no large town is ever quite free, and it varies 
much in severity. Epidemics differ from each other in this 
respect, and case from case. To be infected from a mild 
form is no guarantee of an equally mild attack, etc. It is 
a disease which spreads by infection, though it is often 
difficult to fix the source of contagion. 

Incubation. — This is somewhat variable. It may be only 



SCARLATINA. 211 

a few hours — in many cases it is stated not to exceed forty- 
eight hours, and it rarely exceeds seven days. Consequently 
any one who has been exposed to the poison of scarlet fever. 
and who does not sicken within a week of quarantine, may 
be pronounced safe. The disease is generally latent at this 
stage, and the child retains its ordinary health. 

The Prodromal Stage is short; so much so that it is 
common to find a child quite well, or apparently so, till it 
suddenly turns pale and vomits ; and from that time onward 
it is seriously ill, its extremities perhaps cold, fever high, 
and its whole aspect one of dulness and exhaustion. The 
disease may set in with convulsions or bad headache, but 
this is not common. More often there is some soreness of 
throat for a day or two before the child regularly sickens. 

Eruptive Stage. — Within a very few hours of the initial 
symptoms, during which the child will be more or less heavy 
and prostrate, and in high fever — perhaps vomiting fre- 
quently, perhaps with bad headache, perhaps convulsed — 
the eruption appears. It is seldom delayed beyond twenty- 
four hours. The rash consists of a general rosy blush upon 
which are set minute, darker red points, the surface being 
smooth unless, as often happens, it is accompanied by 
miliaria. Some authors state that the dark red points in 
the eruption are sometimes distinctly raised. In case the 
rash is not too diffuse, the healthy colored skin peeps out 
here and there. The puncta may be even petechial in 
places. The rash appears first about the neck and shoulders, 
and rapidly spreads over the trunk and extremities. It is not 
always evenly diffused ; on the contrary, it is sometimes so 
patchy as to create a doubt about the diagnosis. For 
instance, it may be seen almost confined to the buttocks, 
the back or the ankles, and the editor met with a case 
in which it was confined to the left arm and shoulder 
for nearly forty-eight hours. The face is said by some 



212 DISEASES OF CHILDREN. 

authors not to be often affected, but this is not strictly cor- 
rect. There is not the punctate rash seen in other parts, 
but a diffused blush is by no means uncommon. The rash 
is accompanied by some swelling of the skin. The outbreak 
of the eruption is attended with a still rising temperature, 
with increased soreness of throat, and with a very rapid 
pulse. The extreme rapidity of pulse is indeed one of the 
characteristics of scarlatina, and it goes for little as an indi- 
cation of the gravity of the case. A pulse of 160 is no 
uncommon feature. The sore throat is due to some swell- 
ing of the tonsils, but more especially to a general swelling. 
There is vivid redness of the whole mucous membrane, 
which may often be seen before the rash appears on the 
skin. The tonsils, uvula, and palate generally are highly 
injected and swollen. The tonsils are covered with secretion 
of puriform appearance, and are more or less ulcerated after 
the third or fourth day. The tongue at the same time is 
thickly furred with a white or creamy fur, through which 
peep brightly red swollen papillae. The edges of the tongue 
are often free from fur, and are brightly red, the papillae 
being bulbous-looking from swelling. This constitutes the 
" strawberry tongue." The fur gradually cleans away as 
the disease subsides, and leaves an unnaturally raw, red- 
looking surface. In severe cases the throat is badly ulcer- 
ated, or shows patches of membrane upon it. The lymphatic 
glands in the submaxillary region are enlarged — in mild 
cases moderately, in bad cases much. At this stage the 
urine should be free from albumen. It is usually somewhat 
scanty with diminished chlorides, and later with diminished 
phosphates. It may give evidence of a trace of blood by 
the guaiacum test, and there may even be albumen or casts. 
The temperature rises very quickly to any height between 
102° and 105 °, and it remains high for three or four days. 
It gradually subsides as the rash disappears, and if no com- 



SCARLATINA. 21 3 

plications arise, becomes normal in seven or eight days. It 
is often hindered in its descent, however, by a dispropor- 
tionate severity of the disease of the fauces — ulceration of 
the mucous membrane, or swelling of the lymphatic glands 
— and many young children pass into a condition not easily 
described, in which the temperature remains high, with a 
raw, red condition of the mucous membrane of the mouth, 
a dry skin and general debility lasting for many days. 

At the end of a few days, desquamation begins. In nine- 
teen cases noted by Hillier, its commencement varied from 
the sixth to the twenty-fifth day. The skin, having remained 
harsh and dry meanwhile, now becomes covered with small 
branny scales, while about the palms of the hands and soles 
of the feet larger scales are detected. Exceptionally in these 
parts the entire epidermis is shed en masse as a glove, the 
nails, perchance, coming off also. The natural duration of 
the desquamating stage is well-nigh unlimited — the scales 
being like the dead leaf or blade of grass which depends 
upon external force for its removal — but it is advisable to 
determine it as quickly as possible, and this may be easily 
done by the frequent repetition of warm baths, scrubbing, 
and frequent oiling. 

Modifications. — Such, shortly stated, is typical scarlatina. 
But this is hardly sufficient — it is necessary again to remind 
the student that there is no disease which deviates more from 
a type than this does. The time-honored description of 
three forms — the simple, anginal, and malignant — testifies to 
this. No such subdivision will be adopted, for the simple 
reason that there are so many varieties or degrees of severity 
which pass as such, that it is less perplexing to the student 
to follow existing authors in stating, generally, that some- 
times it is so mild that the illness is hardly appreciable, and 
there is either no eruption or it is of the very slightest 
amount ; sometimes the eruption fades in a day or two in 



214 DISEASES OF CHILDREN. 

place of lasting five or six days. Again, the intensity of 
the disease in the throat varies much. It may be very little; 
it may, on the other hand, be attended with extensive ulcer- 
ation and even the formation of membrane. At another 
time the fauces may at the most not indicate any severe 
affection, while yet ulceration is insidious, progressive, and 
ultimately extensive. As regards the disease in the throat, 
it is the most regular in its appearance of all the symptoms ; 
it is certainly often present when scarlatina is rife without 
any other symptom, and patients thus lightly affected are 
for the most part protected from subsequent infection. In 
young children, it is well to remember that it may be 
present to a considerable extent and pass unnoticed, the 
refusal to take food which indicates its existence being 
attributed to the anorexia of the febrile state. The enlarge- 
ment of the lymphatic glands at the angle of the jaw is the 
best evidence of its presence and its extent, and whenever 
there be any swelling at the angle of the jaw, a careful ex- 
amination of the fauces should be made. 

The accompanying chart (Fig. 4) will give an idea of the 
temperature and pulse range of a case of ordinary severity. 
The patient from which the record was taken was a girl of 
eight years ; the evening before the first observation was 
made, she complained of some headache, nausea, and sore 
throat ; there was, however, no evidence of fever to the nurse's 
hand. The night's rest was much broken with several 
attacks of vomiting. On the morning of the day marked 1, 
the rash appeared; the highest point was marked on the 
evening of the third day. After reaching ioo° F., on the 
morning of the sixth day, an increased angina, with slight 
membranous deposit on the tonsils and considerable swell- 
ing of the glands at the angles of the jaw, set in and pre- 
vented complete lysis until the morning of the sixteenth day. 

With reference to the question of malignancy, scarlatina is 



SCARLATINA. 



215 



a disease which, like small-pox, is sometimes so destructive 
that its entrance into the system is sufficient to put a stop 
to all the natural processes, and to bring about coma, col- 
lapse, and death within a few hours, as already narrated. 
In cases such as this, the child vomits, the temperature runs 
up to perhaps 105 , the pulse becomes very rapid and feeble; 



Fig 



F. 
105 = 

IO4 
103° 
I02° 
lOI 
IOO° 

99° 
9S° 
97° 


M E M E 


M E 


ME M E M E 


M E M E 


ME ME ME 


MEMEMEMEME 






































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Day 

of Dis 


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12 13 14 15 16 


Pulse. 


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TEMPERATl-KE CHART OF SCARLATINA. 



the extremities become cold, the face lividly pale, and there 
is often profuse sweating. In a less rapidly fatal and more 
prevalent form, the fever runs on for four or five days with 
delirium, perhaps vomiting, and the child succumbs, ex- 
hausted, with dry tongue, and possibly stupor, convulsions 
and coma, towards the end of the first week. 

Complications. — Strict!}- speaking these are few in number. 



2l6 DISEASES OF CHILDREN. 

The ulceration of the fauces may be extensive and lead to 
hemorrhage, or to the rapid formation of glandular ab- 
scesses, or even to sloughing of the skin. The inflamma- 
tion of the fauces sometimes extends to the larynx, as in 
diphtheria. Then again convulsions may suddenly set in, 
generally in association with the sudden onset of albumin- 
uria, but sometimes they may be associated with the onset 
of meningitis — which is, however, a rare complication — or 
with the commencement of some intercurrent inflammation. 
Sometimes in severe cases, as already noticed, there ensues 
a condition of coma and rapidly fatal collapse. Diarrhoea 
is sometimes troublesome ; occasionally, too, the joint affec- 
tion known as scarlatinal rheumatism may set in early, and 
may be associated with endo- and, more rarely, with peri- 
carditis, and it may be that in severe cases the synovitis may 
be of a destructive form, and the joint rapidly fill with pus, 
or thin purulent fluid. Scarlatina may be associated with 
other exanthems and fevers. Dr. Goodhart has seen the 
eruptions of varicella and scarlatina both out at the same 
time. Dr. Gee has seen the same. Diphtheria or typhoid 
fever may either of them run concurrently with it — the usual 
experience is that scarlatina has occurred in the course of 
typhoid fever — and both measles and small-pox are occa- 
sionally superadded to scarlet fever. The supervention of 
diphtheria is very likely to be fatal, but measles and vari- 
cella neither alter their course, nor that of the scarlatina, nor 
do they necessarily increase the gravity of the prognosis. 

And here may be mentioned what has been called surgi- 
cal scarlatina. It has been noticed by many observers that 
a red scarlatinal rash sometimes appears after operations, 
the nature of which has seemed doubtful from its quick 
appearance within a day or two of the operation, and the 
modified course which it often runs — chiefly in the direction 
of mildness and rapid subsidence. From what has already 



SCARLATINA. 2\J 

been said on the incubation of scarlatina, these will seem 
but hazardous distinctions with which to combat the scarla- 
tinal nature of this affection ; and there is now no longer 
any doubt that it is true scarlatina for the following reasons, 
which are admirably stated by Dr. Gee : That it occurs in 
epidemics ; that a severe case (with bad sore throat and even 
albuminuria) occasionally relieves the monotony of the mild 
form; that the disease is not exclusively confined to patients 
who have been subjected to operation ; and lastly, that how- 
ever freely these patients are subject to scarlet fever con- 
tagion afterward, they do not contract the disease. It might 
be thought that an operation or open sore would naturally 
render its subject more liable to develop a disease which is 
propagated by fomites, since erysipelas is known to attack 
such cases with peculiar readiness, and probably enters by 
the wound. But from some observations made by Dr. Paley 
and Dr. Goodhart at the Evelina Hospital, it appears probable 
that the poison does not gain an entrance by this means ; for 
the antiseptic treatment of wounds, a most effective bar to 
the occurrence of erysipelas, is none to the advent of 
scarlatina. Several interesting hypotheses have been ad- 
vanced to explain the readiness with which operation cases 
develop scarlatina. Sir James Paget attributes it to the 
lessened resistance induced by the surgical operation. It 
appears, however, that being by no means confined to the 
subjects of recent operations, the more probable explanation 
is that some modified process of incubation takes place in 
any inflammatory focus that may be existent. This, how- 
ever, is not the place to discuss a question of such a kind — 
the important point, in the author's opinion, for the student to 
lay hold of is, that surgical scarlatina is true scarlatina, how- 
ever modified, and must be dealt with as such. In spite of 
the opinion of Dr. Goodhart and the authorities above men- 
tioned, there seems to be considerable weight of authority 



2l8 DISEASES OF CHILDREN. 

upon the other side of the question. The American editor 
has seen several cases in which a rash closely resembling that 
of scarlatina appeared within a short time after an operation. 
One particularly interesting case, was that of a boy twenty 
months old ; the child had a delicate skin, and had frequent 
attacks of eczema ; for one month before an operation for 
phimosis he had been confined to the house by an attack of 
bronchial catarrh, and consequently had no direct exposure 
to the contagion of scarlatina. Twelve hours after the 
completion of the operation, a red punctated rash appeared 
over the whole surface of the body ; this lasted for thirty-six 
hours and then rapidly disappeared. There was no vomiting, 
nor coating of the tongue ; and neither sore throat, elevated 
temperature nor rapidity of the pulse. Moreover, the baby's 
brother, eight years old, who came in close contact with 
him, and might have been exposed to contagion , never de- 
veloped scarlatina. The condition presented by this patient 
seems to be typical of what American physicians term 
" surgical scarlatina." The term is a bad one, however, for 
there is nothing scarlatinal in these cases but the rash ; a 
much better title would be surgical roseola. Of course 
there can be no question that surgical cases may be attacked 
by true scarlatina, and one must be most careful to thor- 
oughly investigate, that the serious disease may not be 
mistaken for the harmless one. 

Relapses of scarlatina are not very rare. Hillier mentions 
the case of a student who had had three attacks, and a week 
after his third attack he had a distinct relapse. Thomas 
describes pseudo-relapses in which a roseolous eruption 
breaks out after the fever has run its course. They gener- 
ally terminate favorably. 

A second attack of scarlatina in the same individual is 
much more common. Indeed, of all the exanthemata, scar- 
latina is the one which is least protective against recurrence. 



SCARLATINA. 2IO, 

The Iargfc majority of persons are exempt, however, from 
any typical recurrence, but when scarlatina is prevalent, 
sore throats are common even in those who have suffered 
from the disease at some former time. 

Sequela? are numerous. They are — nephritis, leading to 
albuminuria and dropsy; dropsy without albuminuria; con- 
vulsions; serous inflammations; glandular abscesses; diph- 
theria; otorrhcea; rheumatism, etc. 

Scarlatinal dropsy, always understood to mean nephritis 
and albuminuria, may occur at any time, and should always 
be watched for throughout the attack. It most usually 
begins during the desquamative stage, but it may begin in 
the eruptive. If the urine be carefully tested, a transient 
albuminuria, or the presence of blood, is probably not 
uncommon in the first week of scarlatina, and a severe 
nephritis may begin suddenly as early as the fifth day. As 
a rule, however, the stage of desquamation is the time for 
albuminuria, and the urine should be carefully tested day 
by day until this stage is completed. The frequency of 
albuminuria appears to vary in different epidemics. Some 
practitioners may be found who have but seldom come 
across it, and who indulge in the belief that it results from 
neglect or bad treatment. This is not correct. There can 
be no doubt whatever that the materies morbi of scarlatina 
is particularly obnoxious to the kidneys. In the early days 
of the fever the urine will often reveal by excess of mucus, 
epithelium, hyaline casts, and occasionally by blood and 
transient albuminuria, distinct evidence of renal disturb- 
ance; children, too, become dropsical and albuminuric 
while yet in their beds, and with the eruption still out 
upon them. Nevertheless, this is a wholesome belief, 
as it makes for what is a powerful prophylactic treatment, 
and there can be no doubt that much less would be heard 
of scarlatinal dropsy were children dieted more strictly, 



220 DISEASES OF CHILDREN. 

and confined during convalescence more rigorously to bed, 
or to their room, than has often been the custom hitherto. 

The albuminuria varies so much in duration, according 
to the severity of the nephritis that occasions it, that it is 
impossible to speak in any precise way of its course. In 
mild cases it may last only a few days, the albumen never 
being in large quantity. If there be much albumen and 
blood, then there is severe disease of the kidney, and its 
course will be a lingering one, lasting perhaps a month or 
six weeks, and often much longer. Nevertheless, it does 
occasionally happen that a considerable quantity of blood or 
albumen appears quite suddenly, and disappears in the course 
of a day or two, almost as rapidly. It is said most commonly 
to set in toward the end of the second week ; but so long as 
desquamation lasts, an uncertain period of some weeks, there 
is a chance of its recurrence. In thirty-four of Dr. Good- 
hart's cases it set in — in the first week in two, in the second 
in eight, in the third in seven, in the fourth in nine, at some 
later period in four, and in four the relation to the eruption 
was uncertain. It usually sets in with fever, perhaps with 
vomiting, and the pallor which comes over the child's face 
is often most striking. The pulse does not present those 
characters of resistance or hardness which are recognized 
so quickly in adults. It is stated to become preternaturally 
slow, fifty to sixty. It is more common to find it irregular. 
The evidence of cardiac disturbance is indeed often striking. 
The impulse is displaced outward, and may be felt sometimes 
at one spot, sometimes at another. The beats are irregular 
in their force, and halting in time ; the first sound may be 
thick and murmurous, or accompanied by a distinct systolic 
apex bruit, and the second sound is accentuated. Twelve 
cases out of thirty-four gave evidence of heart disturbance 
such as this, and in six of the twelve there was a distinct 
bruit. The urine quickly presents characteristic appear- 



SCARLATINA. 221 

ances ; it becomes scanty, is passed frequently in small 
quantities, and is either smoky or deposits a dirty-brown 
sediment, or may be port-wine colored from the presence of 
pure blood in quantity. It is usually highly albuminous, 
and shows blood corpuscles, large epithelial and hyaline 
casts, and much granular detritus under the microscope, but 
there is much variation in this respect. In the less acute 
cases the albumen may be in moderate quantity, the color 
but little removed from a normal standard, and urates present 
in considerable quantity. The dropsy of the face, and in 
severe cases of the subcutaneous tissue generally, is prone 
to follow quickly, and seemingly often suddenly. When 
the disease runs a favorable course, the albumen may remain 
in the urine in quantity for four or five days ; but it quickly 
diminishes, the blood disappears, the urine increases in 
quantity, urates begin to be passed in quantity, and gradu- 
ally all the symptoms disappear. 

Unfortunately there are many other less favorable results. 
The disease may set in with convulsions, or the urine may 
become gradually more scanty, the dropsy more extreme, 
and convulsions supervene after four or five days or more. 
Convulsions are necessarily serious, and are often fatal; but 
in many cases they subside, the child remains drowsy for a 
few days, and gradually comes round again. 

At another time a child will seem to be doing well, with 
but a moderate amount of dropsy and albuminuria, when 
somewhat suddenly its breath becomes short, coarse rales 
appear in all the bronchial tubes, and death follows quite 
rapidly, and not uncommonly, suddenly and unexpectedly. 
These are they who are said to die by acute oedema of the 
lung, but in some of whom at any rate acute dilatation of 
the ventricles of the heart takes place, and with this oedema 
of the lungs and sudden death. In other cases the serous 
cavities become full, in conjunction with extreme anasarca 
l 9 



222 DISEASES OF CHILDREN. 

— a state of things more usually present in the more chronic 
cases. Ascites may be present at any time, and is not 
necessarily of serious omen in acute cases, provided that 
the pleura and pericardium remain free. Dr. Goodhart has 
seen other cases where, in the second or third week of, 
perhaps, quite a mild attack of scarlatina, haematuria — not 
necessarily extensive — has set in, and the urine has gradu- 
ally diminished in quantity up to almost complete suppres- 
sion. This without any dropsy, and with, in fact, no other 
signs distinctive of the disease. On the contrary, in all 
there has been a small, feeble pulse, a distinct and feeble 
first sound, and they have died by asthenia. He has once 
or twice been tempted into giving a hopeful prognosis in 
such cases, and has had to regret it afterward. Dr. Broad- 
bent has alluded to the ominousness — excluding lardaceous 
disease — of nephritis with low arterial tension, and Good- 
hart has seen, both in children and adults, some striking 
examples of the truth of this. 

On the other hand, the nephritis may commence insidi- 
ously, without any of the ^symptoms indicative of acute 
disease, and of course therefore without anasarca. Such 
cases are, however, rare in comparison with scarlatinal 
dropsy. 

In hospital practice, yet another condition must be men- 
tioned as the most largely prevailing of all — viz., where 
children are brought for dropsy, many weeks after some 
indefinite attack of illness which we can only suppose has 
been scarlatina. In these cases also the onset of the renal 
affection is probably insidious. No history can be given of 
any striking alterations in the character of the urine at any 
time, and with considerable albuminuria there is usually 
free diuresis and little alteration of the color of the urine. 

A retrospective diagnosis is often possible in these cases 
from the peculiar appearance of the fingers and toes. Des- 



SCARLATINA. 223 

quamation continues here long after it has ceased in other 
parts of the body, and they present a smooth and shiny 
surface, as if smeared with oil. 

The prognosis must be guarded. 

Meigs and Pepper state that they have never met with 
dropsy after scarlatina in which they did not find albumi- 
nuria. Most writers, however, allude to a condition of 
what, for the sake of distinguishing it, we may call simple 
anasarca, and it is not uncommon. 

The first case that came under Dr. Goodhart's notice was 
in the Evelina Hospital in 1869 — a boy of four, under Dr. 
Hilton Fagge. There was no history of scarlatina, but he 
had been suddenly attacked when in good health a fort- 
night before with frequently recurring vomiting. He had 
been dropsical for four days, and when admitted was suffer- 
ing from general anasarca, ascites and some fluid in one 
pleura. The urine was 1007, and*contained no albumen. 
The anasarca gradually disappeared without any albumi- 
nuria. Since then he has seen several less pronounced 
cases, mostly in the out-patient* room, and within the last 
few weeks another extreme case has been under his care 
in the Evelina Hospital, of which the following are the 
notes : — 

A girl, aged three and a half years ; scarlatina two 
months ago ; ill a fortnight, but not kept in bed. Dropsy 
of the legs began a month ago. When admitted, the child 
was remarkably dropsical, the whole of the subcutaneous 
tissues being affected. The feet were blue and greatly 
swollen. She was in a collapsed condition. There was no 
desquamation. A small quantity of urine obtained con- 
tained no albumen. She was at once put into a wet pack. 
This produced no perspiration, and she passed very little 
urine. The first sound of the heart was reduplicated, and 
there was a slight apex murmur. The oedema rapidly sub- 



224 DISEASES OF CHILDREN. 

sided, and at the end of three weeks had entirely disap- 
peared. The urine was repeatedly examined, and, though 
scanty for the first two days, it never contained any albu- 
men, nor any abnormal microscopical elements. The tem- 
perature was normal throughout. The treatment consisted 
of a milk diet, the wet pack, and an occasional jalap 
purge. Subsequently perchloride of iron was given for 
the anaemia. 

Steiner* writes of this affection thus : "Frerichs has de- 
scribed a rare form of dropsy, without any disease of the 
kidneys, occurring after scarlatina, which he believes to be 
due to paralysis of the cutaneous nerves by exposure to 
cold during desquamation, and Goodhart has seen one 
such case where repeated examination of the urine revealed 
no change, whilst there was very acute dropsy of the skin 
without any effusion into the cavities, which lasted twelve 
days." Thomas f allufles to epidemics in which all the 
dropsical patients were free from albuminuria. HillerJ 
suggests that the slight oedema, with which he alone has 
met, may be due to anaemia, which is often very great, and 
induced with great rapidity. Latterly, Sir Dyce Duckworth 
has published a well-marked instance of this affection, and 
it seems not unlikely from this and other cases that the 
dropsy is related to suppression of the urine, which was a 
very marked feature of the case quoted and also in that 
published by Dr. Duckworth. 

The editor has never met with this condition, although 
two cases of scarlatinal dropsy have occurred in his prac- 
tice in which the urine though non-albuminous contained 
casts, and it seems but just to insist that the absence of 

*" Diseases of Children," Eng. ed., p. 341. 

-j- Ziemssen's " Cycl.," American ed., vol. ii, p. 259. 

J " Diseases of Children," p. 305. 



SCARLATINA. 22$ 

these elements should be proved by careful microscopic 
examination before declaring a dropsy following scarlatina 
to be independent of renal disease. 

At the same time, as suggested by Hillier, it is quite 
possible to conceive that oedema may be due to anaemia 
induced by the fever. 

His cases presented the following histories : — 

The first, a boy three and a half years old, had scarlet 
fever and died subsequently of meningitis. During the five 
months of his illness he had two attacks of desquamative 
nephritis. The first occurred, in spite of every precaution 
in regard to diet and exposure, three weeks after the onset 
of the fever, and subsided a month later. The other began 
one month afterwards, the urine being scanty and smoky 
with a specific gravity of 1030, on acid reaction, and con- 
taining a large quantity of albumen, numerous epithelial 
and blood casts and many free blood corpuscles. In two 
weeks the urine became more copious and commenced to 
clear up, and by the end of another fortnight it was passed 
in abundance, was perfectly clear and contained no albumen, 
but a few granular and hyaline casts. Subsequently on 
four separate occasions, at intervals of several days, the 
urine, which was normal in quantity, color, reaction and 
specific gravity, was carefully examined and found to be 
absolutely free from albumen, though the microscope re- 
vealed many hyaline and slightly granular casts. 

The second case, a boy five years of age, had scarlatina 
in February. The attack was so light that the child was 
not considered ill enough to be put in bed or to require a 
physician. When first seen in March the hands and feet 
were still desquamating, there was considerable anasarca and 
a clear history of a precedent scarlet rash and fever. The 
urine was diminished in quantity, acid, dark-colored, de- 
posited a soot-like material on standing, and contained a 



226 DISEASES OF CHILDREN. 

quantity of albumen and numerous epithelial, granular and 
hyaline casts. 

He improved rapidly under treatment, and three weeks 
later the dropsy had nearly disappeared. The urine con- 
tained a few hyaline casts, but no albumen. Then there was 
a slight return of renal congestion indicated by the re- 
appearance of the soot-like deposit and a small amount of 
albumen. After four days the urine was again clear and 
free from albumen, but a few hyaline casts were discovered. 
During the next four weeks, as the feet were occasionally 
cedematous, the urine was examined repeatedly and found 
to contain hyaline casts though it was non-albuminous. 

Serous inflammations are not uncommon after scarlatina, 
and they are liable to be of a suppurative form. Empyema 
is the most common, but suppurative pericarditis and peri- 
tonitis have both been known to occur. Endocarditis, 
meningitis, and inflammation of the joints must also be 
mentioned ; the two latter, however, cannot be dissociated 
from the . rheumatic affection, which will be considered 
immediately. An acute empyema may possibly prove fatal; 
the pus being often thin, rapidly formed, and attended with 
severe constitutional disturbance ; but as a general rule 
purulent effusions do well. 

Glandular abscesses in the neck are very common. In 
young children they are apt to be associated with a diffuse 
inflammation of the cellular tissue of the neck, and some- 
times with extensive sloughing of the skin. In other cases 
there is a diffuse brawny infiltration of the tissues of the 
neck, rather than any definite glandular affection. In either 
case the complication is a serious one. When the abscess 
is circumscribed and confined to one gland or so, there is 
not necessarily any ground for alarm. 

Diphtheria has already been mentioned as a complica- 
tion ; it is usually fatal as such, but it occasionally occurs 



SCARLATINA. 227 

later, with equally disastrous issue, either by extending to 
the larynx or by the exhaustion of the recurrent fever. 

Otitis is very common. The inflammation may be limited 
to the external passage, or spread up to thecniddle ear by 
the Eustachian tube from the disease in the pharynx. In 
the latter case particularly — and in any case, if the discharge 
be of long continuance — disease of the bone is apt to arise, 
and either permanent deafness or worse happens. 

Of late years scarlatinal rheumatism has been much 
talked about. It is a common sequela; occurring some- 
times during the eruptive stage, it is more common toward 
the end of the second week or later. It is quite like acute 
rheumatism, as we know it in childhood, from other causes, 
and shows itself, sometimes by pains only, more or less 
manifest, sometimes by swelling of the larger joints. 
Steiner states that it affects the knee and elbow by prefer- 
ence, but Goodhart has more often seen the wrists and 
ankles affected. It is rarely attended by pericarditis ; com- 
monly by endocarditis ; or rather it is frequently associ- 
ated with a systolic murmur at the apex of the heart, but 
in many cases this bruit disappears. Probably about five 
per cent, of the cases of scarlatina develop a murmur, but 
the majority of such bruits disappear within a short time. 
The relation of this affection to acute rheumatism is still 
uncertain. Henoch discards the term rheumatism, and pro- 
poses that the affection shall be called scarlatinal synovitis; 
but Goodhart has seen several cases in which there was a 
strong family history of acute rheumatism — so often so that 
he has come to think that it may be a constitutional trait, 
appearing under circumstances of deteriorated nutrition, 
rather than a special feature of the scarlatinal poison. 

It occasionally happens that this scarlatinal synovitis runs 
on to suppuration and destruction of the joint, with symp- 
toms of pyaemia. Such cases have, no doubt, tended to 



228 DISEASES OF CHILDREN. 

throw doubt upon other affections of the joints, it having 
been thought that the pyaemia of the one might be present 
in milder form in the serous inflammation of the other. 
But the suppurative inflammation is so rare that the two 
forms of joint disease may well be due to distinct causes. 
Dr. Ashby, of Manchester, agrees with Henoch in holding 
that the larger number of cases are not of rheumatic origin. 
He thinks them mostly septic, because scarlatinal synovitis 
is more common in some epidemics than in others ; it is 
essentially a complication of the prolonged febrile stage of 
severe throat affection ; the attack usually supervenes at 
the end of the first week ; fewer joints are affected ; a relapse 
rarely occurs ; and because endocarditis is very rare. Ashby 
admits the frequency of bruits both at the apex and left 
base, but he considers them all haemic or functional. The 
editor is also inclined to accept this view. 

There are other sequelae which occur less often — such 
are pneumonia and bronchitis, chronic enlargement of the 
tonsils, wry neck (Goodhart has notes of two cases of the 
latter), chronic diarrhoea, etc. ; and, lastly, may be men- 
tioned as not uncommon, a chronic inflammatory condition 
of the mucous membrane of the nose and mouth, in which 
the surface of the nose becomes excoriated, covered with 
dry crusts, and exudes a thin discharge, while the mouth 
is superficially ulcerated and dotted with thin membranous 
patches, as in other forms of stomatitis. 

Etiology. — It is a disease which spreads by infection, and 
is communicated by means of the exhalations and secre- 
tions, and also by the scurf from the desquamating skin. 
It is little infectious, perhaps not at all so, during the stage 
of incubation, but the risk rises .during the eruptive, and 
reaches its height in the desquamative stage. Doubts have 
been expressed by many whether it may not arise de novo ; 
but, as it is endemic and widely spread, and is even not 



SCARLATINA. 229 

unknown in domesticated animals, such as horses, dogs, 
and cats, in no case can it be said that infection is impos- 
sible, and consequently there is but little use in discussing 
a question upon which doubt is dangerous". Further, the 
germs of scarlatina appear to retain their vitality for long 
periods, and cases are on record where a fresh outbreak of 
the disease has occurred months and even so long as a year 
after a former one, owing to the housing and subsequent 
use of improperly disinfected clothes. The poison can in 
this way be carried for long distances by such things as 
letters or books, and in this respect it differs from measles 
and other exanthems ; but in direct contagion it appears 
to be less intense than that of either whooping-cough or 
measles. It can also be conveyed by articles of diet. Of 
late years outbreaks have been traced unmistakably to the 
contamination of milk. The poison has been shown to be 
effectually destroyed by exposure to a heat of 21 2°, from 
which it follows that all clothes, woollen or linen stuffs — 
everything, in fact, that can be so treated — must be sub- 
jected to a dry heat of at least 21 2° for some hours before 
they can be considered to be disinfected. The poison is 
further possessed of extreme tenacity, and for this reason 
there is often great difficulty in efficiently disinfecting houses 
or rooms, and the fever breaks out again and again after 
what has seemed to be the most thorough disinfection. 

Upon these considerations depends the answer to the 
question, when may a child who has had scarlatina mix 
with other children ? Not until desquamation is over, and 
six weeks is about the necessary quarantine, provided that 
the child has been carefully tended with reference to this 
matter. Desquamation will linger for two or three months, 
if not hastened by proper attention to the cleansing of the 
skin. The author thinks it advisable to act with perhaps 
exaggerated caution in such matters. It is often a question 
20 



23O DISEASES OF CHILDREN. 

of sending a child back to school, where it comes into 
close contact with perhaps a large number of healthy 
children, and where contagion, if conveyed, will be most 
disastrous. It is much better in such a case, that the one 
child should suffer the, after all, but slight loss entailed by 
an extended holiday, than that any risk should be run by 
the many ; and he does not hesitate to extend such partial 
quarantine to two, or even in some cases, three months. 
The medical man has to certify to the clean bill, and upon 
him lies all the responsibility. He need indeed be cautious, 
considering the dangers of scarlatina. Ten days is sufficient 
isolation for a child who has been in contact with the fever, 
provided he and his clothes have been disinfected. No 
child must go to school or mix with children of other 
families while scarlatina is in his own home. 

Morbid Anatomy. — Of morbid changes there are none 
sufficiently constant to make them pathognomonic. Micro- 
cocci have been discovered in the blood, and it is probable 
that we are on the eve of more positive information in this 
direction. All the known facts point to a definite conta- 
gium, although we cannot yet identify it. 

Of macroscopic changes we may expect to find, during 
the height of the fever, perhaps some mottling of the skin, 
oedema of the fauces, with livid congestion or ulceration ; 
perhaps suppuration of the tonsils. The lymphatic glands 
in the neck are swollen, as also may be the mesenteric 
glands and other glands of the body. The cervical glands 
may be suppurating, or in severe cases are imbedded in a 
diffuse oedema. Thomas alludes even to extravasation of 
blood around them as a result of intense inflammation. 
There is really nothing to note elsewhere. The bronchial 
tubes have been found injected, and the spleen is at times 
swollen, but this organ is by no means so frequently affected 
as in typhoid fever. 



SCARLATINA. 23 1 

Microscopically various changes have been found. Fen- 
wick has noted an infiltration of the rete mucosum with 
leucocytes ; and to some active processes of cell growth of 
this kind set up by the fever must be attributed the later 
symptom of desquamation. Klein has found that minute 
changes go on in the viscera, particularly in the kidney, 
spleen, liver, and lymphatic glands. Some of these — for 
example, the hyaline degeneration of the intima of the small 
arteries, and the parenchyma of the liver and kidney — may 
be no more than the conditions dependent upon the febrile 
state, for they have been found by several observers in other 
pyrexial states than scarlatina ; but it is important to note 
that, in addition to these, Dr. Klein has found in the early 
days of scarlatina (within the first week), that there is a 
hyaline change in the Malpighian tufts of the kidneys ; that 
the epithelium of the capsule shows signs of disturbed func- 
tion by proliferation ; and that the muscle nuclei of the 
small arteries undergo similar changes. Further, when the 
disease extends on to the tenth day, there then appears an 
extensive accumulation of leucocytes in the connective tis- 
sue around the renal vessels and tubes. Thus we have 
anatomical evidence, within the first week, of the action of 
the scarlatinal poison upon the kidney. The changes, 
indeed, are very similar in kind, to those that have been de- 
tected in the skin. The risk of nephritis is thus clearly 
indicated, and the warning given to watch and take care of 
the kidneys. In this stage there will be little or nothing 
morbid in the general appearances of these organs ; they 
may perhaps be over-full of blood, but no conclusion can be 
drawn from that. The later stages of scarlatinal nephritis 
show to the naked eye enlargement or swelling of the kid- 
neys, and with this increased resistance when handled or cut. 
The surface becomes mottled from the admixture of the 
natural color with patches of opaque yellow or buff, and, 



232 DISEASES OF CHILDREN. 

more closely examined, the surface is seen to be speckled 
with minute yellow dots, and the section is muddled from 
loss of the natural streaky arrangement of the alternating 
vascular and tubal areas. The amount of this yellow or 
buff material varies much, and with it the appearance of 
the organs. When extreme the aspect will be that of the 
large white kidney, but, so far as Goodhart has seen, it is 
not often that such is the case. There may also be very 
advanced changes in the kidneys, with but little pronounced 
departure from the natural appearances. The kidneys may 
be rather paler than natural ; perhaps a more buff tint, but 
as to which there would be a doubt had we no clinical 
evidence to go upon, and no microscopic examination to 
further us. Microscopically, however, the changes are 
fairly constant. There are the appearances of glomerular 
nephritis. These are such as have been enumerated above, 
but in addition, we find extravasation of blood or fibrinous 
material into the capsule, with more marked epithelial pro- 
liferation of the lining of the capsule and of the tuft itself; 
the tuft is either turgid with blood, or pressed back to one 
side of the capsule by the extravasation ; and there are hya- 
line thickenings of the capsule, and peri-glomerular collec- 
tions of leucocytes. In addition to all these the renal 
tubules are choked with cloudy or fatty epithelium ; there 
are peri-vascular aggregations of inflammatory products in 
parts other than the capsules ; local patches of congestion 
with the vessels crowded with blood ; and casts in some or 
other of the tubes, composed sometimes of blood, sometimes 
of fibrinous material. It is the more or less of this change 
and of that, at one time or another, which makes up the 
variety of pattern and gives perplexity to the student, so 
that it is necessary to insist upon the fact that a very bad 
kidney may not reveal itself decisively to the naked eye. 
The morbid changes in the other viscera associated with 



SCARLATINA. 233 

renal disease are not special to childhood, and need but a 
passing mention, with perhaps one exception — viz., dilata- 
tion of the heart. It is usual to find in death from scarla- 
tinal dropsy that there is both ascites and hydrothorax, 
while the lungs are small, of a dull leaden hue; their bases 
being solid from an cedematous pneumonia, the upper part 
being deficient in air, and a copious frothy fluid exuding 
on pressure. This is the condition called acute oedema, a 
well-recognized condition toward the end of a case of 
chronic parenchymatous nephritis. There is very likely to 
be double pleurisy in addition, perhaps pericarditis or endo- 
carditis. But it has not been very generally known that 
the ventricles are liable to be dilated. Dilatation of the 
heart is recognized as an occasional result of the scarlatinal 
poison or of the fever engendered by it, but it is not this to 
which allusion is now made. It is more important to 
impress upon the student that ventricular dilatation is not 
uncommon as the result of scarlatinal nephritis. It is in- 
deed, a common result of chronic nephritis in adults ; but, 
while adults probably but seldom die from acute dilatation 
of the heart in acute renal disease, children are liable to die 
quite suddenly. In this, perhaps, may be found the expla- 
nation of a difference which exists in renal disease between 
the pulse of children and of adults. The hard pulse of 
chronic renal disease in adults is well recognized, and ob- 
viously it is the combined result of two factors — obstruc- 
tion in the capillaries or small arteries, and compensatory 
muscular action on the part of the heart. The power of 
cardiac compensation is most striking in adults; it is less 
evident in childhood ; and therefore acute dilatation of the 
heart must be watched for and guarded against. Dr. Good- 
hart has once seen diffuse suppuration in the wall of the 
heart in scarlatinal nephritis. It occurred in a girl of three 
and a half years, thirty-one days after the onset of the 



234 DISEASES OF CHILDREN. 

fever.* Such a case is perhaps of more value in empha- 
sizing the tendency that exists in scarlatina and its sequelae 
to changes in the muscular wall of the heart, than in itself 
it would otherwise be. 

To dilatation of the heart must also be attributed some 
of the cases of hemiplegia which occur after scarlatina ; but, 
these being common, most writers mention their occurrence. 
Some cases are due, no doubt, to dislodgment of clots 
from the inflamed valves, others from the formation of 
thrombi in the trabecular pouches of a dilated ventricle. 

Of other morbid changes which are more or less prone 
to associate themselves with the post-scarlatinal state, there 
remain to be mentioned empyema ; suppurative peritonitis ; 
suppuration in one or other of the joints ; suppuration in 
the middle ear with disease of the petrous portion of the 
temporal bone; periostitis and necrosis of the long bones; 
sloughing of the glands of the neck and the superficial 
skin ; cancrum oris and broncho-pneumonia. Even this 
list might be extended, but without any great advantage, 
for all these are but occasional occurrences, although, when 
scarlatina claims so many victims during the year, they can 
hardly be said to be uncommon. 

Diagnosis. — When in doubt, admit it, and act on the 
assumption that the disease is scarlatina. Rotheln, roseola, 
bastard measles, German measles, and all such terms are of 
bad reputation, and are only to be admitted when the evi- 
dence is indisputable that the attack is not scarlatina. 
There may often be a doubt, but the public is to have the 
benefit, not the eruption. Scarlatina may be mistaken for 
measles when the latter is more diffused and less raised 
than usual, or when the scarlatina is less diffused and more 
livid than usual ; a scarlatinal rash sometimes precedes the 

* " Path. Soc. Trans.," vol. xxxi., p. 70. 



SCARLATINA. 235 

eruptions both of measles and variola — the latter by no 
means uncommonly, but variola is hardly one of the dis- 
eases of children. The Wvidity and elevation of the spots 
are to be attended to in addition to the coryza which is so 
characteristic. 

Rotheln is characterized by a rash which is sometimes 
like scarlatina, at another like that of measles. At one- 
time there is much coryza and angina, at another none; and 
of individual cases it may be impossible to speak decidedly. 
But it occurs in epidemics, runs a short, sharp course, 
without much illness, without desquamation, and without 
sequelae. 

Tonsillitis is usually one-sided, and limited to the tonsil. 
The glands at the angle of the jaw are all but quiescent. 
There is no preceding vomiting, the attack is sporadic, 
acute upon some chronic enlargement, and is not very com- 
mon in childhood. Roseola, if it can be distinguished, is of 
a lighter tint; less papular-looking, may be traced to food 
or drink, etc. Dr. Gee mentions that the swelling of the 
joints which sometimes occurs in scarlatina before the out- 
break of the eruption had been mistaken for rheumatism. 

Prognosis. — An attack ushered in by convulsions is nearly 
always fatal, and severe delirium is also a symptom of great 
gravity. Other symptoms of bad omen are excessive py- 
rexia ; nasal discharge ; evidences of failing circulation — 
lividity of the surface, excessive rapidity and feebleness of 
the pulse — diarrhoea; any tendency to exhaustion, with sordes 
in the mouth, membrane on the fauces, severe sweating, etc. 

Treatment. — Uncomplicated and mild scarlatina requires 
no treatment during the eruptive stage except confine- 
ment to bed, the substitution of fluid diet — milk being the 
chief element — for that of ordinary health, and a mild 
aperient every other day or so. The room is to be well 
ventilated, kept at a uniform temperature of 65 °, and the 



236 DISEASES OF CHILDREN. 

bed and body-linen changed frequently. Nevertheless, it 
is with mild cases that there is so much trouble. Perhaps, 
a child is hardly ill, and the parents do not see the necessity 
of three weeks in bed, and the doctor does not insist upon 
it. It is allowed to get up, perhaps to go out of its room, 
and then dropsy supervenes. Dropsy, no doubt, varies in 
its frequency in different epidemics, but this does not alter 
the fact that it may be averted in many a case by timely 
care. Three weeks, at least, in bed, and a further fortnight 
or three weeks in one room, make the proper preventive 
treatment for this complication. The editor insists upon 
six weeks in bed even in the mildest cases. 

If the eruption is fully out and the fever high, a warm 
bath night and morning will give much relief. When 
the fever is excessive, tepid sponging must be resorted to, 
and in some well-selected, extreme cases, the cool bath as 
described under the head of measles, or the wet pack. For 
the soreness of throat, an electuary of equal parts of the 
glycerinum boracis and honey may be given in small 
quantities at frequent intervals. 

Inunction is advisable in most cases as soon as the erup- 
tion appears. It relieves the stiffness and itching of the 
skin ; it reduces the temperature ; it stimulates the circu- 
lation, is agreeable to the patient, and promotes sleep, and 
thus tends to better the disease. Carbolized oil (1 to 40) is 
a very good preparation, possessing as it does disinfecting 
properties. Meigs and Pepper recommend cold cream, to 
which a drachm of glycerine per ounce has been added — a 
very nice preparation, which may easily be made disinfectant 
by substituting the glycerinum boracis for the pure gly- 
cerine. The inunction may be applied as often as necessary 
— two, or three, or more times a day. Antiseptic inunction 
must be insisted upon, and some very strong evidence of 
its value has been of late adduced by Dr. Jamieson, of 



SCARLATINA. 237 

Edinburgh. He asserts that he lias by tin's means com- 
pletely prevented the spread of infection from the sick to 
the healthy. From the first onset of the fever the patient 
is anointed from head to foot (including hair), morning and 
evening, with the following ointment : — 

R. Acidi carbolici, gr. x\x 

Thymol, gr . x 

Vaseline, ^j 

Ungt. simp., 5J. M. 

SlG. — Use freely twice each day. 

A hot bath is given every night, and the fauces are painted 
frequently with glycerine of boric acid. During three years' 
trial of this plan of treatment Dr. Jamieson has never known 
the infection to spread. 

If not resorted to before, a daily warm bath should be 
commenced as soon as desquamation begins. Plenty of 
soap and water and friction hasten the completion of this 
stage. Care must, of course, be exercised to avoid any 
chill, but this can readily be done by having a bath at iOO°, 
and a large, warm towel or sheet to envelop the body during 
the process of drying, and in which the child may be carried 
back to bed. In the more severe cases the temperature 
will probably be higher, and the cooling processes a more 
important element in the treatment. Cold sponging, the 
tepid bath, or the ice-pack must be resorted to more freeh- 
and, in cases where there is much delirium, an ice-cap may 
be applied to the head with advantage. The editor, as 
already hinted, would draw attention to caution in the use 
of cold sponging or the pack ; these are powerful remedies 
and must be employed with judgment. 

Much depends on feeding. The throat is sore, and the 
child refuses food in any shape. It must be coaxed with all 
the variety the nurse or physician can suggest. Barley- 
water, with uncooked white of egg added to it ; simple water 



238 DISEASES OF CHILDREN. 

and egg albumen ; nutrient jellies, blanc-manges, chicken- 
broth, veal-broth, Brand's essence, milky whey, all readily 
suggest themselves as valuable in turn. To these must be 
added stimulants, either brandy, champagne, or port wine. 
When food by the mouth fails, nutrient and predigested 
enemata must be tried; but they are not very well borne by 
children. Dr. Goodhart is disposed to think more highly of 
the catheter passed through the nose into the stomach, and 
of regular feeding conducted through it. As regards local 
treatment, when the faucial inflammation is severe, there is 
much difference of opinion. Meigs and Pepper think that 
the good that might accrue is often nullified by the exhaus- 
tion produced in the struggles of resistance. There can 
be no doubt, however, that, when it can be applied, some 
glycerine preparation gives such relief that children will 
often submit readily to the reapplication. We cannot say 
dogmatically that one preparation is better than another. 
Personally, we are in favor of boracic acid and glycerine, 
or of this in combination with bicarbonate of sodium, 
whenever there is any tendency to the closing of the fauces 
by viscid mucus or membrane, but perchloride of iron, 
glycerine, and chlorate of potassium are very useful. The 
inhalation of steam, impregnated with carbolic acid or 
eucalyptol, is always advisable, and a spray of lime-water 
and the sucking of ice are both well worth a trial in suitable 
cases. 

Internally perchloride of iron, chlorate of potassium, car- 
bonate of ammonium, and quinine are the most serviceable 
drugs when drugs are needed. The chlorate of potassium 
may be given in three- or four-grain doses with five or 
six drops of hydrochloric acid and a little syrup of Tolu, 
etc. This is useful in adynamic cases, or when the 
throat is much affected. The editor often employs the 
following : — 



SCARLATINA. 2yj 

R . Potassii chloratis, gr. xxiv 

Tr. ferri chloridi, TT^xxiv 

Syr. zingiberis, f^j 

Aqua;, q. S. ad fj§ vj. M. 

SlG. — Tablespoonful every two hours at the age of six years. 

Carbonate of ammonium is also a valuable stimulant in 
severe cases, two or three grains being given in milk every 
three or four hours. Quinine should be given if the tem- 
perature keep up beyond four or five daws, and the rectum 
is the best channel of administration. 

Of drugs for cutting short the exanthem, none have as 
yet any claim to trust. Belladonna has been tried and 
abandoned. Hyposulphite of sodium in five-grain doses, 
and sulpho-carbolate of sodium are thought well of by 
some, and salicin is a good remedy when there is much 
fever. Dr. Illingworth, and Dr. Dukes of Rugby, have 
spoken very highly of the biniodide of mercury, both in 
respect of its power to cut short the disease and also to 
influence for good the scarlatinal nephritis. Children take 
a solution of the perchloride of mercury well, and to it may 
be added some iodide of potassium, one, two, or three 
grains, as may be considered advisable. Dr. Illingworth 
also strongly recommends the biniodide in suspension as 
an application to the throat. He takes two ounces of the 
solution of perchloride of mercury,* and adds gradually a 
solution of I in 4 of iodide of potassium or sodium until a 
cloudy red liquid is obtained ; to this is added half an 
ounce of glycerine for the purpose of suspension. 

The complications and sequelae of scarlatina, excepting 
the nephritis, must be treated each of them on its own 
merits ; but this general rule will apply, that, resulting from 
fever, they are generally an indication of the need for stimu- 
lants and tonics. 

* B. P. It contains bichloride of mercury and chloride of ammonium, each 
ten grains to one pint of distilled water. 



24O DISEASES OF CHILDREN. 

In scarlatinal dropsy, the child — if not already in bed — 
must be at once sent there. The diet is to be fluid, the 
bowels are to be regularly opened by jalapin (gr. j) or scam- 
mony (grs. v to vij) or seidlitz powder once a day, and the 
skin is to be acted upon by a warm bath night and morn- 
ing. The bath should be ioo°. The child should be im- 
mersed up to its chin and allowed to remain in it for fifteen 
or twenty minutes, care being taken to keep up the tem- 
perature of the water the while. It is then to be wrapped 
in a dry warm blanket and put to bed again. Should these 
measures not be successful, dry cupping to the lumbar 
region may be added, and frequent hot applications by 
means of spongio-piline. Digitalis should be given inter- 
nally for two purposes — first, to keep up the flow of urine, 
and secondly to guard against the occurrence of dilatation 
of the heart. The tincture may be given by itself, in one-, 
three-, or five-minim doses every two or three hours, or in 
the following mixture : — 

R. Tr. digitalis, f-5 ss 

Liq. ammoniae acetatis, f ^ iss 

Spt. aetheris nitrosi,' fgij 

Syr. tolu, f ^ ss 

Aquae cari, q. s. ad f^iij. M. 

Sic — A teaspoonful every two hours for a child of six or eight years. 

Ten or fifteen minims of the infusion every three hours is 
sometimes more successful than the tincture. Dr. Good- 
hart prefers to give digitalis with citrate of potash in quan- 
tity sufficient to keep the urine alkaline, in this respect 
following Dr. Roberts of Manchester. The quantity of the 
potash salt must be fixed for the case ; it may be any quan- 
tity from five grains every three or four hours upward. 
The tincture of strophanthus will also prove useful as, in 
addition to its action upon the heart, it certainly has a very 
striking diuretic action in some cases. 

Should there be any tendency to suppression of urine 



SCARLATINA. 24I 

and should convulsions threaten, immediate and repeated 
resort must be had to all these means. Purgation must be 
free, and bromide and iodide of potassium should be given 
internally. Diuretics are recommended by many. Dr. 
Goodhart prefers to trust to the action of bowels and skin 
rather than run the risk of further blocking an organ already 
at a standstill from hyperaemic conditions. In this condition 
a warm wet pack — by means of a blanket wrung out of hot 
water — for two or three hours at a time, is very useful, and 
in bad cases he has used subcutaneous injections of pilocar- 
pi, though not with any striking success. 

The editor has found that infusion or fluid extract of 
jaborandi administered by the mouth acts very efficiently, 
especially if combined with hot packs. For the latter pur- 
pose the child, stripped of its clothing, is placed between 
blankets and surrounded by bottles containing hot water 
and covered with flannel cloths wrung out of hot water- 
The pack should last from ten minutes to half an hour, 
according to the amount of sweating and feebleness induced. 
It may be repeated when there is little prostration twice 
daily. Should the child complain of faintness while under- 
going this treatment the bottles must be removed at once 
and a dose of whiskey given. 

Hot-air baths are useful in producing diaphoresis, but are 
more apt than the packs to produce faintness and a sensa- 
tion of difficulty in breathing. Heated air may be intro- 
duced, the child being blanketed as before, by a tube 
leading from an inverted funnel held over a gas jet or spirit 
lamp. 

When the acute symptoms subside — the dropsy diminish- 
ing and diuresis becoming established — then is the time for 
iron. Tincture of the chloride is useful ; under its use the 
albumen will decrease, the blood disappear, and the anaemia 
become much less manifest. Sometimes milder prepara- 



242 DISEASES OF CHILDREN. 

tions are required. If so, reduced iron, or carbonate of 
iron, or Parrish's food may be resorted to. 

The following formula, which differs somewhat from 
" Basham's Mixture," is perhaps the best way of adminis- 
tering iron in these cases. 

& . Tr. ferri chloridi, f^j 

Acidi acetici dil., f 5 jss 

Liq. ammonii acetat., fgx 

Elix. aurantii, fgv 

Syrupi, fli 

Aquae, q. s. ad f ^ vi. M. 

SlG. — One tablespoonful three or four times a day, for a child of four 
years. 

The kidney is not an organ that repairs quickly. Con- 
sequently if the albuminuria is of any duration the child 
must be kept in bed for some weeks. When the albumen 
has disappeared there is still need for much caution. The 
clothing must be very warm — flannel next to the skin — and 
the diet must be the most assimilable possible. It should 
consist largely of milk for a long time, and meat is to be 
entirely avoided. Open-air exercise is to be resorted to 
gradually, and only at first on the warmest days, and if the 
parents are in a position to allow of it, a temporary sojourn 
at some temperate watering-place is very desirable. 

Scarlatinal rheumatism is to be treated by salicin or 
salicylate of sodium in the same way that acute rheumatism 
is treated ; but to young children the salicylate should be 
given with caution ; severe vomiting and collapse may be 
produced by it. Perhaps a grain for each year of life may 
be considered an adequate dose with which to commence. 
It may be given every three or four hours till the pain is 
relieved ; and then at less frequent intervals, and subse- 
quently combined with quinine. 

For otorrhcea a good syringe should be procured and 



SCARLATINA. 243 

the ear gently washed with warm spirit lotion (fyss to 5x) 
three or four times a day, or boracic acid may be blown 
into the meatus, or the following applied : — 

I£. Ungt. hydrarg. nitrat., 3J 

Glycerinse, f.^j 

01. carbolici (1-40), fj^fij. M. 

After syringing, a little oil should be dropped into the 
ear, and some salicylic wool kept in the meatus. 

When there is a discharge from the nose it is advisable 
to pass up the affected nostril a brush which has been im- 
mersed in glycerinum boracis, or in an ointment composed 
of fifteen grains of iodoform or iodol, and half an ounce of 
the oil of eucalyptus, to an ounce and a half of vaseline. 

Preventive Treatment. — No doubt in the future we shall 
have adequate hospital accommodation for fever patients, 
and homes for those who are convalescent; at present, 
when out of reach of these means, we must come as near 
as may be to the sanitary requirements of the day. Tne 
child must be kept in the one room, its nurse or nurses 
occupying another on the same floor. All unnecessary 
stuffs and linen, carpets, etc., are to be removed from that 
floor. Sheets steeped in carbolic acid are to be hung from 
the doors of the rooms, and a similar disinfectant is to be 
sprinkled freely over the floor. No actual contact is to be 
allowed with the rest of the household, and all linen from 
the sick-room is to be steeped in some disinfectant before 
removal. This quarantine must be rigidly enforced and 
maintained throughout the illness — that is to say, until des- 
quamation is completed — an irksome and difficult task 
enough. When the term of quarantine has expired, the 
child should have a final bath, leave all his clothes behind 
him and don a clean outfit outside his room ; after this he 
may be considered to be clean. 



244 DISEASES OF CHILDREN. 

After the exit of the patient and his nurses, the rooms 
occupied by them must undergo a thorough disinfection. 
Sulphur should be burned in them for some hours. The 
papers stripped, the ceiling rewhitened, the floors scrubbed 
with carbolic soap, and all bedding and linen which cannot 
be subjected to prolonged boiling must be sent to some 
disinfecting oven and subjected to prolonged heating at a 
temperature over 250 . Clothing in like manner, and, 
where expense is no object, everything in the way of cloth 
or wool that has been contaminated, should be burnt. 

When a case of scarlatina breaks out in a school it is a 
good plan when possible to have the temperature of all the 
children taken night and morning. By this means very 
early isolation can be effected, and there is every chance in 
this way of arresting the spread of the disease. 

3. Rotheln (Epidemic Roseola ; Bastard Measles ; Ger- 
man Measles ; Rubella) — is an affection which appears to 
have been noticed at various times in the last hundred years ; 
but many, even yet, have seen little or nothing of it, and 
doubt its existence. There is not, however, any longer 
room for doubt that an exanthem is occasionally present 
with us which in some things resembles scarlatina, but, in 
more, measles. Originally it was thought by many to be a 
hybrid between scarlatina and measles, now it is commonly 
supposed to be a distinct species. But the one opinion 
does not exclude the other ; there are, e.g., some who think 
that diphtheria — from certain peculiarities in its history and 
associations — is a disease in which the germ of what will 
be, but is not yet, a distinct species is in process of evolv- 
ing ; that it is in fact an illustration of the tendency which 
plants exhibit of varying under domestication — and, indeed, 
what can be more likely ? We know that in the cultivation 
of plants variations occur, and that hybrids are grown which 
can occasionally be propagated so as to constitute them 



ROTHELN. 245 

distinct species. Why should exanthem germs be alto- 
gether exempt from such tendencies to variation ? Thus, 
when we have to do with a disease which is at one time 
more like scarlatina, at another like measles, but always to 
some extent like both, and always wanting some of the 
features of both, there is not only no difficulty in consider- 
ing the disease a hybrid, or a derivative of one disease or 
the other, but also none in regarding it as a distinct, though 
perhaps as yet but an imperfectly stable species, and one 
which, regarding its probable source, is of the greatest pos- 
sible etiological value. Naturally we must be very cautious 
in accepting any conclusions upon such a point. Eruptions 
very lik"e scarlatina, very like measles, are undoubtedly pro- 
duced by various articles of food, drugs, and so on. It will 
not do, therefore, to conclude, because of the existence of a 
nondescript rash, that some new exanthem has started into 
existence. We only wish to maintain that there is no inherent 
objection to this derivative view, and that until we know 
more of the nature of the " germ," it will be as well to keep 
our minds open. But in thus stating dogmatically that the 
existence of a distinct exanthem which resembles two others, 
but is neither, is proved, it may be stated that the affection 
is an uncommon one, and that the diagnosis is to be arrived 
at with the greatest possible circumspection. " German 
measles " is a term which is terribly abused. A doubtful 
rash makes its appearance, and the medical man, instead of 
saying he is not certain of its nature, calls it German measles. 
" Then it is not scarlatina? " ask the parents. " No," says 
the doctor ; and the parents, thinking nothing of measles, 
take no precautions. Any hospital physician sees many 
such cases, and knows also very well — considering the 
rarity of the actual disease — that when he has to do with 
the after effects of what is called German measles, it is more 
probable than not that the malady has been scarlatina, and 
21 



246 DISEASES OF CHILDREN. 

that in this direction he must look for the explanation of 
whatever sequelae he may meet with. 

As regards its specific entity it may be pointed out, that 
it occurs in epidemics ; that one attack appears to be pro- 
tective against a recurrence ; and that it is no protection 
to have suffered previously from scarlatina and measles. 
Of sixty-three cases seen by Dr. Dukes, thirty-nine had 
had measles, twenty-three had not. If anything, it appears 
to be more common in adults, at any rate in young adults 
or adolescents — a class of whom a larger number are pro- 
tected by previous attacks of scarlatina and measles than 
in younger children. Conversely, those who have suffered 
from rotheln procure no immunity from scarlatina or mea- 
sles. Dr. Thomas states that it is especially a*disease of 
childhood, attacking indiscriminately older and younger 
children down to sucklings, susceptibility being essentially 
weakened at puberty, and nearly lost after forty. 

It is very contagious, though less so than measles. In 
an epidemic at Charterhouse, recorded by Dr. Haig-Brown, 
in spite of the most active precautions as to isolation and 
disinfection, the disease spread from a first case to two hun- 
dred and two others. The infective power is said to exist 
for a month, so that strictly a child should be isolated for 
that time. But the disease is one of so little severity, that, 
except in the case of weakly children, it can hardly be 
necessary to keep up any strict quarantine after ten or four- 
teen days. As a matter of practice, provided one is sure 
of the nature of the disease, there can be but little objection 
to allowing a child to return to school at the end of a fort- 
night, if thorough disinfection has been carried out. 

Definition. — Dr. Squire thus writes of it : " A specific 
eruptive fever; the rash appearing during the first day of 
the illness, beginning on the face in rose-red spots, extend- 
ing next day to the body and limbs, subsiding with the fever 



ROTHELN. 247 

on the third day, and not preceded by catarrh, nor followed 
by desquamation. Slight branny desquamation on the face 
is not uncommon. 

Incubation. — This lasts a fortnight or more, during which 
period the child is quite free from symptoms. Dr. Dukes 
records thirty-six cases, in twenty-five of which the incuba- 
tion is given ; in one or two only was it twelve days, in the 
remainder from fourteen to twenty-two days. In seventy- 
five of Dr. Haig-Brown's cases it varied from seven days 
to seventeen days, in sixty-six of them being from nine to 
fourteen days. 

The Eruptive Stage may be well illustrated by a case : A 
woman who always enjoyed good health, was quite well till 
May 20th ; she felt out of sorts and depressed all day, with 
lumps in her neck, and on May 21st, in the early morning, 
an eruption appeared and she was seen immediately. The 
temperature was then 98.6 , the pulse 80. The face and neck 
were covered with a red raised eruption, consisting of clus- 
tered papules rather thickly set, but the intervening skin 
being white and healthy-looking. There was no soreness 
of throat, but well-marked, rather hard, and not tender, 
enlargement of the glands on both sides of the neck. She 
felt perfectly well. The next day the rash had become much 
more diffused ; the face now presenting a livid appearance, 
with a general red ground and lumpy raised elevations 
upon it. Over the chest there was a roseola not unlike 
scarlatina, but less punctate. The temperature still remained 
normal. The next day she was well, and no desquamation 
followed. 

Here we have all the characteristics well marked : twenty- 
four hours of the most moderate indisposition; the outbreak 
of an eruption like measles, though attended by a roseola 
not unlike scarlatina; the absence of catarrh, such as is 
characteristic of measles ; the absence of the desquamation 



248 DISEASES OF CHILDREN. 

characteristic of scarlatina ; considerable temporary swelling 
of the glands of the neck, but no sore throat, no fever at any 
time; and the affection running its entire course in four 
days. 

Some latitude must be allowed both to the definition here 
given and to the type which is illustrated by the case. For 
instance, the eruption, though usually raised in coalescing 
points like measles, is occasionally diffused, and unquestion- 
ably more like scarlatina ; pyrexia may, or may not, be 
present : it is always moderate when present ; there may 
alsp be some slight catarrh, and occasionally there is some 
slight branny desquamation. But these features are present 
in only the minority of cases, and will then necessarily tend 
to obscure the diagnosis. Dr. Dukes describes a mild and 
a severe form. In the latter the eruption is profuse and the 
temperature up to 103 , and Dr. Haig-Brown reports cases 
where it ran as high as 105 . Complications and sequelae 
there are none, so that if after an attack of German measles 
a child remains thin and feeble or has any discharge from 
its ears, these things indicate that some error in diagnosis 
has been made, and the disease was either scarlatina or 
measles. 

Diagnosis. — Allusion has already been made to the liability 
that there appears to be to mistake rotheln for scarlatina 
and measles. It is only necessary to add that the possi- 
bility of eruptions produced by drugs and food must be 
borne in mind when forming an opinion, and Dr. Dukes 
mentions also the frequent occurrence of a measly rash which 
is caused by handling some species of caterpillar — a very 
common hobby with boys at school. Great diagnostic value 
has been attached to the enlargement of the posterior cer- 
vical glands ; it is a common symptom, but it is frequently 
absent. Drs. Wilcocks and Carpenter have noticed it 
absent, and Dr. Haig-Brown also, in the epidemic already 



ROTHELN. 249 

quoted, eighty-four times to seventy-five in which it was 
present. 

Treatment. — The child must be kept warm in one room, 
and in bed, if possible, for a day or two, but this is not 
absolutely necessary; some saline diaphoretic may be given, 
and a mild aperient may be indicated. Here, as in any 
other exanthem, the clothing must be attended to after the 
attack, the child being kept warm and guarded from chills, 
and, should any debility show itself, an iron tonic should 
be given. 

The room inhabited by the child during the attack must 
be fumigated afterward as for other exanthems. 

4. Roseola, or rose rash, has no strict right to be con- 
sidered in association with the specific exanthemata; but the 
chief point of the affection is the difficulty of the diagnosis 
— a question of such moment as quite to justify the departure 
from any mere scientific arrangement. Rose rash is an 
irregular mottling or blush upon the skin, dependent appa- 
rently upon gastric disturbances. It lacks the minute bright 
red punctiform appearance of scarlatina, and is sometimes 
more like measles in mottling the skin. It is generally 
diagnosed by the absence of any definite symptoms of 
scarlatina, and, experimentally, by the fact that it has not 
in any given case spread by contagion. 

But let it be indelibly impressed upon the student that 
it is often very difficult to distinguish this complaint from 
scarlatina, and that a mistake may be followed by the 
gravest consequences. Many a case of rose rash has 
proved itself in the result to have been scarlatina. There- 
fore, unless there is no doubt, it is safer to take precautions 
as if the more serious disease were present. Rose rash 
stands in this respect with surgical scarlatina or mem- 
branous croup. It is probable that there are scarlatinal 
eruptions which are not scarlatina, and membranous inflam- 



25O DISEASES OF CHILDREN. 

mations of the larynx which are not diphtheritic, but they 
can seldom be distinguished. Many such cases prove 
indisputably to be of the graver sort, and for the safety of 
others, in default of conclusive evidence to the contrary, all 
should be so regarded. So too should it be with roseola, 
for scarlatina now stalks about as often as not in the garb 
of innocence, and does incalculable harm both to the patient 
and to those with whom he comes in contact. For instance, 
two children suffer from a red rash, called rose rash by the 
doctor, who commits himself positively to the non-scarla- 
tinal nature of the affection. But subsequent observation 
shows that they have sore throat ; a servant in the house 
has a bad throat; and the aunt also has a bad throat, and is 
unwell for some weeks. Of the patients themselves, both 
subsequently have enlarged cervical glands and desquama- 
tion, and one has discharge from the ears and albuminuria. 
Another child has what is called rose rash ; but it remains 
sickly afterward, and has a discharge from its ears, and 
does not regain strength for some weeks. Now, inasmuch 
as roseola is a very transient and trifling matter, and is fol- 
lowed by no sequelae, when a child remains weak and thin, 
with a red raw tongue, dry skin, and has discharge from 
the ears after such an attack, it is probable that a mistake 
has been made in the diagnosis, and that scarlatina has 
been the disease. The above are both cases that actually 
occurred, and every one of us must know of many more of 
a similar kind. A more careful examination of such cases, 
with this in mind, will often lead to the detection of a gen- 
eral fine branny desquamation, or some flakiness of the 
cuticle on the hands and feet. Such children are abroad in 
numbers, wholesale purveyors of scarlatina; and they will 
continue to be so, so long as roseola or rose rash is of 
common occurrence. Our attitude is not to ignore its 
possible existence, but to accept it only upon the strongest 



ROSEOLA. 251 

evidence; and the usually accepted evidence — viz., absence 
of pronounced symptoms of scarlatina — is not strong enough, 
for there is no disease which is more variable both in the 
intensity of single symptoms and in the grouping of those 
which may be considered typical. 

Treatment. — When we are sure that we are dealing with 
roseola, very little treatment will be required. Some sim- 
ple saline, such as citrate of potassium with acetate of 
ammonium, and warmth in bed for twenty-four hours, with 
light diet for a day or two, will probably be all that is 
necessary. 

5. Diphtheria is a disease very frequent among chil- 
dren ; it is most common between the ages of two and ten. 
It is usually considered to be due to a specific poison, because 
it is often epidemic and it is certainly contagious. But 
there are points in its natural history which differ much 
from many other specific fevers, and of these it may be 
mentioned that its contagious power is not a very high one. 
It is communicated by one patient to others by means of 
inoculation from a materies derived from the diseased parts, 
and thus doctors and nurses are chief sufferers ; an imper- 
fectly disinfected tracheotomy tube may impart it ; a healthy 
child put into a bed or a particular corner of a room recently 
occupied by a diphtheritic child may thus " catch " the 
disease, but it is not communicated to other children or 
patients in a building, or carried about in clothing, like 
measles or scarlatina. It has also a curious tendency 
much more frequent with it than with other specific fevers, 
though not unknown in them, of tacking itself on to some 
other fever. Thus measles followed by diphtheria, scarla- 
tina followed by diphtheria, typhoid fever followed by or 
going with diphtheria, are all well known and not uncom- 
mon. Epidemics of all these three — measles, scarlatina, 



252 DISEASES OF CHILDREN. 

and typhoid — occur, in which diphtheria attacks many, so 
that some have thought it wanting in specific quality and 
capable of being bred out of these diseases. Its relation- 
ship to scarlatina appears to be unusually close. Again, if 
membranous croup and diphtheria are one disease, as very 
many now hold, diphtheria is endemic, for sporadic cases 
are very common and appear to keep company in a large 
number of cases with no other known source of contagion 
than bad-smelling drains. There is indeed much to be said 
in favor of a pythogenic origin de novo in these cases. It 
differs from other specific fevers in having no proper erup- 
tions attaching to it, being often without any at all ; it some- 
times possesses one of scarlatinal character, sometimes 
one like that of measles, more often perhaps an anomalous 
patchy roseola — in virulent cases the rash may be petechial. 
Lastly, unlike other specific affections, diphtheria has no 
powerful protective influence against another attack at some 
future time. 

Incubation. — This stage appears to be somewhat uncer- 
tain. It ranges from two to eight days — three days being 
a usual time to elapse between the reception of the germ 
and the first symptom. 

The Attack is characterized by the formation of tough 
yellowish or grayish membrane upon a mucous surface, 
generally of pharynx or larynx, combined with local inflam- 
mation. The local symptoms are associated with certain 
so-called constitutional symptoms — viz, fever and albumin- 
ous urine. Different cases vary in many respects. The 
type is pharyngeal diphtheria, but sometimes the membrane 
forms not upon the fauces, but on the conjunctiva or the 
labia pudendi, oftentimes in the larynx. Sometimes it in 
great measure confines itself to the nasal mucous mem- 
brane ; sometimes it may be found upon the lips, sometimes 



DIPHTHERIA. 253 

on some sore upon the skin ; sometimes no membrane is 
present, yet the remainder of the symptoms make the case 
indistinguishable from one of diphtheritic nature. So with 
the albuminuria. In some cases it is pronounced and per- 
sistent ; in others it is moderate in quantity throughout; in 
others it quickly disappears. The pyrexia too maybe of all 
grades of intensity : sometimes so little that the child is 
able to sit up in its bed and play with its toys ; sometimes 
the constitutional disturbance is so severe that the condi- 
tion is desperate even from the commencement. 

The onset in pharyngeal diphtheria is usually some- 
what slow, the child is out of sorts, heavy-eyed, languid and 
pale, for four or five days, by which time the temperature 
reaches perhaps ioi°. The throat is now seen to be red 
and swollen, and predominance of redness or lividity over 
swelling is of evil omen. The appearance of the throat in 
a simple tonsillitis is, usually speaking, a more juicy or 
cedematous one than the perhaps less swollen, but firmer- 
looking, thickening of the parts in diphtheria, and the swell- 
ing is more often unilateral. The membrane begins as small 
patches of yellowish material, not in themselves distin- 
guishable, or at any rate certainly so, unless perhaps occa- 
sionally by their dirty color, from the plugs of welded 
epithelium and secretion which issue from the mouths of 
the follicles of the tonsils in the course of tonsillitis, both 
acute and chronic. Their nature has to be decided partly 
by their position — if they are on the soft palate, provided 
of course that we are not dealing with thrush, they are of 
membranous nature — also by their roughness ; by the gen- 
eral appearance of the throat ; by the constitutional symp- 
toms ; pain in swallowing; fever, and glandular swelling. 
At this time the glands beneath the angle of the lower jaw 
on one or both sides should be hard, tender and slightly 
enlarged, but the swelling is not necessarily great, though 
22 



254 DISEASES OF CHILDREN. 

in severe cases it is often considerable.* The diphtheritic 
plaques tend to increase in area, and to coalesce ; they 
adhere rather stoutly to the surface of the palate or tonsil, 
and when removed a shallow ulcer is seen, with numerous 
bleeding points upon it. The urine is usually of good color, 
good specific gravity, and a moderate cloud of albumen is 
precipitated if cold nitric acid be added. It seldom contains 
blood. Hyaline, and occasionally epithelial casts may be 
found by microscopic examination of the urinary sediment. 

In addition to the symptoms above mentioned there are 
early in the attack : chilliness, pain in the back and limbs, 
headache, thirst and fever. Prostration, in proportion to the 
length of time the patient has been ill, is very marked. The 
pulse is frequent, weak and easily compressed. Opening 
the jaws produces considerable pain, and the neck is fre- 
quently much swollen. The breath is very fetid, and at 
times membrane tinged with blood is coughed up. The 
voice is altered, and the cough, should the larynx be 
involved, is croupy. 

In a case of this kind terminating favorably, the mem- 
brane perhaps remains in situ for some three or four days, 
and then slowly disintegrates, disappearing in perhaps ten 



* Dr. Goodhart writes : " I would insist particularly upon this hardness of 
the glands at the angle of the jaw in diphtheria, as it is often a most charac- 
teristic feature. I have lately seen an outbreak of the disease in a school 
where, with a few cases of pronounced diphtheria, a large number of the 
children suffered from a diffuse fleshy thickening and ulceration of the tonsils 
and fauces, and in a great many of them the glandular hardening was striking. 
It may remain for some little time after the throat is apparently well. I think, 
too, that this feature is not without an etiological value when considered in con- 
junction with the fact that in this disease, perhaps alone of all the contagious 
febrile diseases, the spleen wants the puffmess which is one of their chief 
characteristics. The spleen of diphtheria is almost always moderately firm, 
but I have not had the opportunity of examining many cases of the virulent 
pharyngeal form." 



DIPHTHERIA. 255 

days from its first appearance, and the child slowly regains 
its former state of health. When the membrane clears 
away, a somewhat indolent, though shallow ulcer is usually 
left behind, which is often slow in healing up, and is fol- 
lowed, or not, as the case may be, by paralysis of the soft 
palate. And this may be so even when the evidence of real 
illness has been but slight. In favorable cases the albu- 
minuria disappears — sometimes with peculiar suddenness — 
in a few days, but it may last even in considerable quantity for 
some time after the subsidence of the throat symptoms. 
This outline of the symptoms is subject to several modifi- 
cations. 

(1) There may b.e much membrane about the soft palate 
and fauces, and very little constitutional disturbance, and 
no albuminuria — e.g., a girl, aged ten years, had been ill for 
twelve days with sore throat. The urine contained no 
albumen at any time, the temperature only reached 99 , 
and she hardly seemed ill, yet the sides of the fauces were 
covered with membrane, her cough was croupy, and there 
was decided dyspnoea. She was treated with chlorate of 
potassium and perchloride of iron internally, with a local 
application of bicarbonate of sodium, and recovered. (2) 
The membrane may be considerable, the constitutional 
symptoms slight, but albuminuria considerable, and after a 
few days the child may die almost suddenly, either from 
collapse or sudden syncope. (3) The throat affection may 
be severe, the fauces, soft palate, and uvula being covered 
by thick leathery lymph, and some parts perhaps sloughing, 
in which case the constitutional symptoms will almost cer- 
tainly correspond in severity. The nasal mucous membrane 
is then liable to suffer, and a thick offensive discharge issues 
from the nostrils and crusts about the anterior nares ; or 
there is a foul, acrid, serous and sometimes bloody discharge 
from the nostrils which produces excoriation and swelling 



256 DISEASES OF CHILDREN. 

of the upper lip; the fever is high, the pulse rapid, the 
albuminuria copious, and the prostration and somnolence 
profound. These cases if seen early usually present the 
livid appearance about the mouth and the anxious facial 
expression so indicative of obstructed respiration. (4) The 
throat symptoms may be slight, the fever severe, and the 
general symptoms those of bad blood-poisoning, death 
occurring within a day or two, or even less. (5) The fauces 
may show no membrane, but the tonsils and parts around 
are in a condition of acute phlegmonous inflammation. Dr. 
Goodhart has seen cases of this kind where the tonsils 
sloughed out en masse, and in which death occurred by 
sudden failure of the heart. (6) The laryngeal symptoms 
may be paramount, or the disease may be entirely confined 
to the larynx, but there can be no doubt that in many of 
these cases (called " croup ") the early faucial inflammation 
has been overlooked from the insidious manner of onset 
peculiar to the disease. The sore throat may be devoid of 
all specific character, the resulting malaise and anaemia, per- 
haps more than is readily explicable ; but the true nature of 
the disease is first proved by the onset of paralysis. 

Causes of Death. — No case of diphtheria, however mild, 
is free from danger. There are four principal risks : a. Of 
blood-poisoning, b. Of some inhibitory action upon the 
heart, causing slow pulse and syncope, c. Of asthenia. 
d. Of extension of the membranous inflammation to the 
larynx, with all the consequences which this involves. 

The last mentioned is, in hospital experience, much the 
more frequent, but perhaps this is only due to the fact that 
as such cases require operative treatment and very special 
nursing, they are therefore more likely to be sent into a 
hospital. 

But to take the various risks in order. 

a. Blood-poisoning carries off some. Cases of this kind 



DIPHTHERIA. 257 

are usually severe from the commencement — probably the 
throat symptoms are excessive ; the nostrils involved ; the 
membrane is plentiful, tough, and dark-colored; the breath 
fetid ; the albumen copious ; the temperature high ; and the 
pulse rapid and feeble. Four or five days sees the termina- 
tion of such a case as this, and death comes either by som- 
nolence, gradually deepening into coma ; or more suddenly 
by a rapidly falling temperature, coldness of the extremi- 
ties — perhaps profuse sweating — and a general lividity of 
the surface; a condition, in short, of septic collapse. 

b and c. All acute inflammations about the fauces show a 
tendency to cause slowing and irregularity of the pulse ; 
this is especially the case with diphtheria and constitutes 
one of the great dangers of the disease. Moreover, the 
symptom is by no means confined to cases of severity, and 
the risk appears to attach not only to the acme of the dis- 
ease, but to the period of convalescence afterward. Cases 
are on record in which sudden syncope has ensued after all 
membrane had disappeared from the fauces, and the ulcers 
remaining were healing satisfactorily. The pulse will sink 
to 50, 40 or even less — Hillier says even so low as 20 — per 
minute, and become irregular ; this condition being asso- 
ciated perhaps with vomiting and a sub-normal tempera- 
ture, and the child is said to die quite suddenly. Dr. 
Goodhart has lately made an inspection of the body of a 
boy of four, under the care of his colleague, Dr. Wilks, who 
had been ill six weeks, and had had paralytic symptoms for 
a fortnight. He was a thin, anaemic boy, and appeared to 
die from exhaustion. The left ventricle of the heart was 
widely dilated, although the muscular tissue looked healthy. 
It may also be added that, in addition to this disordered 
innervation, the action of the heart may be exceedingly 
feeble from fatty degeneration of the muscular fibres of its 
wall. He has seen other cases where there was no special 



258 DISEASES OF CHILDREN. 

heart symptom except a very small pulse — children in 
whom an extreme pallor, restlessness, and resistance to all 
attempts to induce them to take food were the notable 
features of the case. Such usually indicate a fatal ter- 
mination. 

d. The greater proportion of deaths are due to suffoca- 
tion caused by the extension of the membrane from the 
fauces into the larynx and trachea, or by a more or less 
general broncho-pneumonia due to this, or to this and the 
operation of tracheotomy resorted to for the relief of the 
asphyxia. This also is a complication which is more likely 
to ensue in the cases of moderate severity than in those 
which run a more rapid course, and, as stated already, it 
often appears to be the primary affection. But careful 
inquiry generally serves to show a period of four or five 
days' malaise, and Dr. Goodhart has known laryngitis to 
follow pharyngeal diphtheria so late as the twelfth day. 
Some still doubt whether there is such a thing as an un- 
complicated laryngeal diphtheria — that is to say, whether 
there is not in all cases some, even if it be but slight, faucial 
disease as well. Others, on the contrary, go so far as to 
say that whenever a membranous laryngitis is met with it 
is due to diphtheria ; in other words, that membranous 
croup is always diphtheritic. If this be correct, the other 
opinion cannot be; as it is quite certain that a membranous 
laryngitis is met with in which the fauces are free from be- 
ginning to end. In these cases there is slight malaise for 
three or four days ; then a noisy, reedy cough is noticed, 
with slight inspiratory stridor. The temperature of the 
body is as yet hardly in excess, although even already the 
urine may be albuminous. The noisy, hissing respiration 
increases; the temperature rises, the child becomes more 
and more restless, the features become livid and then 
leaden, and unless the windpipe be opened, death ensues 



DIPHTHERIA. 259 

shortly from suffocation. The best gauge of laryngeal 
obstruction is the recession of the weaker parts of the chest 
walls during inspiration ; that of a pressing deficiency of 
aeration is restlessness. A diminution of restlessness, ac- 
companied by the onset of a leaden pallor of the features, 
betokens impending dissolution and the immediate neces- 
sity of tracheotomy. 

Complicatiofis and Sequela*. — These are not numerous, 
albuminuria and paralysis are the chief of them. More- 
over, it may perhaps be mentioned that at times a somewhat 
deep ulceration may be met with about the tonsils, which is 
slow in healing ; and at times, though far less commonly 
than in scarlatina, a diffused brawny swelling of the con- 
nective tissue of the neck, such as has of late years received 
the name of Angina Ludovici. 

The albuminuria of diphtheria requires mention for many 
reasons. It is remarkably constant, though the quantity of 
albumen passed varies much ; should it be persistent, and 
the quantity of albumen be large, although in other respects 
the child may seem to be doing well, the prognosis is of 
considerable gravity. One may notice further that it is a 
symptom of the disease — being present at an early period 
of the attack, generally by the third or fourth day; that the 
urine is not as a rule characterized by scantiness, or the 
presence of blood, and that casts, if present, are hyaline and 
not epithelial ; that it leads to no after-symptoms, such as 
dropsy ; and that the kidney does not usually show any defi- 
nitely marked change. Thus essential differences are estab- 
lished between the albuminuria of diphtheria and that of 
scarlatina : in the one it is an early symptom, in the other 
a late one ; in the one the urine is not characteristic, in the 
other it contains blood and epithelial casts ; in the one it has 
no after-effects, in the other dropsy is the rule ; in the one 
the kidney shows no definite structural change, in the other 



26o DISEASES OF CHILDREN. 

there is a recognized form of nephritis. Gerhardt has found 
peptones in the urine of diphtheria. 

Diphtheritic paralysis, unlike the albuminuria, is an 
affection of the convalescent, and declares itself usually after 
two or three weeks by a paralysis of the soft palate. This 
is known by the peculiar alteration of the voice, and often- 
times by food coming through the nose in swallowing. But 
the paralysis is frequently much more extensive than this. 
It may extend to the external ocular muscles and cause 
squint; to the ciliary muscle and cause dimness of vision 
from erratic accommodation, and to the muscles of the 
trunk and extremities producing a general paralysis, in 
which the child is unable to hold anything or to feed 
himself, or staggers about in a tipsy way, such as is very 
liable to be mistaken for the symptoms of cerebral tumor 
if the practitioner be not on his guard. Dr. Goodhart has 
seen more than one instance of this in out-patient prac- 
tice, where the history of diphtheria has been, as it may 
be, very unobtrusive. It is further not uninteresting to note 
that in diphtheritic paralysis the patella tendon reflex is 
often absent, and this fact, together with the occurrence of 
disturbances of vision, has in adults led to a mistaken diag- 
nosis of ataxie locomotrice. Deafness, loss of taste, and 
disturbance of common sensation are not infrequent. 
Paralysis is to diphtheria what dropsy is to scarlatina, a 
symptom which often leads to the detection of a hitherto 
unsuspected ailment. But in calling diphtheritic paralysis 
an affection of the convalescent, we must not forget that in 
the active stages of the disease we have also a paralysis 
which constitutes one of the gravest dangers of diphtheria — 
viz., paralysis of the heart. One can but suppose, indeed, 
that this is only a part of the same tendency to the implica- 
tion of the nervous centres as is seen in the stage of con- 
valescence, and that in those terrible cases of sudden death, 



DIPHTHERIA. 26 1 

which are by no means uncommon both during the disease 
and convalescence, we have some sudden disturbance of the 
vagus, brought about by means of its cardiac branches. 

Morbid Anatomy and Pathology. — The fauces are more or 
less swollen, and covered with lymph; but the extent of the 
swelling and the amount of lymph may alike be small. In 
the most severe cases the uvula and surface of the pharynx 
generally are sloughy-looking, or the tonsils and adjacent 
mucous membrane are boggy or much thickened from a 
diffuse inflammation. In later stages the parts may be much 
defaced by deep ulcers. But the majority of cases which 
prove fatal, especially in hospital practice, do so from 
laryngitis and extension of inflammation down the trachea. 
The mucous membrane of the epiglottis is thickened and 
crinkled, and a tough adherent membrane lines the laryngeal 
surface of the epiglottis and the interior of the larynx above 
the true vocal cords ; a leathery layer often extends from 
these parts over the edge of the epiglottis to the base of the 
tongue, and over the ary-epiglottic folds to the mucous 
membrane of the pharynx, and the reflection of mucous 
membrane from the pharyngeal aspect of the larynx to the 
pharynx proper is a favorite seat for membrane, and one 
too from which it is not easily detached or reached by local 
applications. As soon as the trachea is reached, the char- 
acter of the membrane alters — it loses its toughness, all 
firm adhesion to the tracheal mucous membrane ceases, and 
it is only in exceptional cases that any tough cast of the 
respiratory passages is obtained. By careful manipulation 
with water a flimsy cast may frequently be separated from 
the trachea and larger bronchial tubes ; but it is more com- 
mon to find the passages full of a thick puriform mucus 
with shreds or granules of membrane ; the mucous mem- 
brane beneath being mottled and thickened from a diffuse 
inflammation of the submucous tissue similar to that found 



262 DISEASES OF CHILDREN. 

in the pharynx. The mucous membrane often fails to show 
any intensity of inflammation, as judged by injection. The 
extent of disease is apparent more by superficial ulceration, 
minute points of suppuration or early membranous forma- 
tion, and a general pink and yellow mottling of the whole 
surface. The smaller bronchial tubes are usually full of 
thick pus, and the lungs in a state of more or less diffused 
broncho-pneumonia combined with atelectasis. It must be 
remembered that in nearly all these cases tracheotomy has 
been performed some hours, if not days, before death, and 
therefore that the morbid appearances below the larynx 
ought perhaps to be considered as a combined result of the 
disease, and of the operation rendered necessary by it. 

But little more need be said — membrane is, very occa- 
sionally, found in other parts of the body, the gastrointes- 
tinal tract, the genital passages, and the intestine should be 
examined, and throat affections are sometimes associated 
with anomalous appearances, such as swelling and injection 
of the glandular patches and solitary glands, or perhaps 
some more diffused enteritis, although no actual membrane 
may be present. But all such things are rare. Certain 
negative facts, however, are probably not unimportant — 
first, that the spleen, which in most conditions of blood- 
poisoning is large, soft, or pulpy, in diphtheria is not 
of abnormal size, and is usually firm ; secondly, the kidneys 
show no change whatever to the naked eye, nor is anything 
very decisive found by microscopical examination. Small 
foci of micrococci with some associated disseminated ne- 
phritis are said to be present. Lastly, a point which is 
perhaps not without value in reference to the pathology of 
the neuro-paralytic symptoms of this disease, in that in some 
cases, in particular epidemics of diphtheria, meningitis has 
been found. Dr. Goodhart once saw such an association of 
morbid changes, but it is a very rare condition in his expe- 



DIPHTHERIA. 263 

rience, and apparently in that of other English patholo^ 
The diphtheritic paralysis appears to be due to a species of 
anterior polio-myelitis of somewhat irregular distribution. 
There are now some sixteen cases published by Dejerine, 
Abercrombie, Kidd, and others, and in all much the same 
changes have been found, It is, however, worth remark 
that no after-results, such as infantile paralysis, have ever 
yet been recorded ; it would appear that most cases get 
perfectly well, though some die, but that between these two 
extremes there is no mean of permanent paralysis. This 
interesting anomaly has been of late discussed by Dr. 
Buzzard in some most interesting lectures on peripheral 
neuritis, in which it is urged that, in opposition to the ob- 
servations just alluded to, and which point to disease in the 
anterior cornua, there are others which support the opinion 
that the disease is of the nature of a peripheral neuritis. 
Dr. Buzzard very justly remarks : " It must be remembered 
that the cases in which disease of the spinal cord has been 
discovered have been of necessity fatal cases ; and the 
question is, what is the pathology of the infinitely more 
numerous cases which not only recover, but recover with- 
out leaving trace of any permanent change ? That, with 
the clinical evidence before us, we are not justified in saying 
that diphtheritic paralysis in its ordinary form, passing to 
complete recovery, is dependent upon an affection of the 
spinal cord. It is, in my opinion, more reasonable to con- 
clude that we have usually to do with peripheral neuritis of 
very varying severity." 

Pathology. — This has been already trenched upon in the 
opening remarks, but repetition will not be out of place in 
a matter of so much importance. Diphtheria is a contagious 
blood disorder — some would say a specific blood disorder, 
meaning thereby a disease due to some definite and constant 
germ ; but we avoid the term specific, because there are 



264 DISEASES OF CHILDREN. 

peculiarities about the disease which must to some extent 
raise a doubt whether it may not result from varied causes. 
For instance, it is associated with or comes on after so 
many different specific diseases. It is a frequent accompani- 
ment of measles, of typhoid fever, of scarlatina. Exposure 
to the effluvia of bad drainage notoriously often precedes 
its occurrence, and catarrh and chronic inflammation of 
mucous surfaces predispose to'it. Secondly, it is not pro- 
tective against subsequent attacks. Per contra, and in favor 
of specific quality, we have the fact that it occurs in epi- 
demics ; that the period of incubation is fairly constant ; 
that the symptoms are also uniform ; and that there is 
abundant proof, both by cases and experiment upon animals, 
that the disease is transmitted by contagion. 

In bygone years, not yet far removed, it has been much 
discussed whether the disease is a local or a general one ; 
but in view of the now prevailing doctrine, that all specific 
fevers are due to the introduction into the blood and tissues 
of germs from without, that question loses much of its 
point. All such affections must now be held to be more or 
less local at first. The difference lies in this — that while 
some germs gain entrance by several doors, or diffuse 
themselves with great rapidity by many means, others pro- 
ceed by more isolated routes, and propagate themselves 
only after some process of maturation in the seat of infec- 
tion. To the latter kind belongs diphtheria. This is well 
shown in the case recorded by the late Dr. Hillier, of an 
eminent surgeon who pricked his finger in the operation of 
tracheotomy upon a child for croup. The next day the 
puncture became painful. The following day a pustule 
formed, and a day or two later the cutis sloughed. This was 
followed in six days by diphtheritic deposit on the tonsils ; 
and, a month later, there was paralysis of the soft palate ; 
partial paralysis of the fingers and legs, and some impair- 



DIPHTHERIA. 265 

ment of sensibility. To this case many others could be 
added, where medical men have been inoculated by ejecta 
from the throat and fauces, while engaged in painting the 
throat ; in operating, or in clearing the trachea of membrane. 
Others could be cited where kissing has conveyed the con- 
tagion. 

Diphtheria, then, is the result of a germ introduced from 
without by direct contact. It, generally speaking, fixes 
itself upon the fauces or throat, and becomes generalized 
from thence ; but supposing it to gain an entrance by some 
other channel, such as the conjunctiva or skin, it still is 
liable to show a partiality for the fauces, and to appear, 
sooner or latter, as a membranous exudation on that part. 
The contagion is not one which readily diffuses itself, and 
therefore direct contact is the chief source of its propaga- 
tion ; but in this way it is possessed of considerable vitality, 
which evinces itself by the persistent way in which it clings 
to a particular room, a bedstead, or articles of furniture 
once contaminated by the sick child. Dr. Goodhart has 
more than once seen a patient infected by means of a bed- 
stead which had undergone what was supposed to be thor- 
ough disinfection. 

The infecting germ is supposed to be micrococcus, 
0.00035-0.001 mm. in diameter, and of slightly oval form. 
These bodies, fixing themselves upon the locality they 
choose, be it the catarrhal throat, the hypertrophied tonsils, 
the cutaneous sore, or otherwise, excite a peculiar membra- 
nous necrobiotic inflammation. At the same time they 
gradually work themselves into the tissues, the lymphatics 
and the blood vessels, and thus are carried to all parts of 
the body. Taking the kidney particularly as the part from 
which definite symptoms of the disease emanate, we may 
pursue the life-history of these bodies further, and it is 
found that they grow in foci within the organ, induce 



266 DISEASES OF CHILDREN. 

hyaline degeneration and block up branches of the smaller 
blood vessels and of the capillary tufts. Thus is brought 
about a cause of thrombosis, of ecchymosis, and therefore 
of albuminuria. It is at present unknown how the nutri- 
tional changes in the nerve cells and peripheral nerves are 
caused, commencing as these do, for the most part, after a 
cL -finite interval of convalescence has elapsed. 

Contagion. — The questions that arise on this head may, 
perhaps, best be stated in a practical way. One child of 
several in a family falls ill with diphtheria ; the others are 
attending various schools; may they still continue to do so, 
or must they first be purged of any possible contamination? 
Now, any one of them may be already breeding the disease, 
so that on that ground all must be kept from school until 
the incubation limit of a week has passed over. So far as 
is known, there is practically no evidence to show that 
diphtheria is carried by an intermediary, not actually dis- 
eased, to a third person, and therefore, strictly speaking, 
such children might safely mix with others. But the inter- 
ests at stake being great, it is generally advised — and Dr. 
Goodhart endorses this rule — that so long as there is diph- 
theria in a house, all the children should be regarded as in 
quarantine. 

A child that has had diphtheria remains contagious during 
convalescence, and probably so long as there is any ulcera- 
tion of the fauces or discharge from the nose. Three weeks 
should be allowed to elapse from the disappearance of the 
membrane before the convalescent is allowed to mix with 
other children, and then only if the throat be healthy and 
there be no discharge from throat, nose, ears, etc. 

Diagnosis. — The student must be prepared with some 
ideas on a question of such importance as this. It has 
already been mentioned incidentally that there are many 
who think nowadays that all cases of membranous croup 



DIPHTHERIA. 267 

are diphtheritic — that membranous croup is that form of 
diphtheria which attacks the larynx. The points of dis- 
tinction usually drawn are these: Croup is a sthenic disease, 
diphtheria is a disease attended by prostration ; in croup 
the urine is not albuminous, in diphtheria it is; croup is 
not followed by paralysis, diphtheria is ; croup is not an 
epidemic disease nor is it contagious, diphtheria is both. 
But these distinctions do not suffice for their purpose, 
because cases of croup are of frequent occurrence, in which 
holding perhaps at first, they afterward fail, perhaps by the 
appearance of albumen in the urine, as is most common ; 
perhaps by some evidence of the possession of contagious 
properties, as the attack of two children in one house, the 
drainage of which is in good order, or the nurse or doctor 
taking the disease ; or it may be by its appearance in an 
epidemic form. Moreover, it cannot now be contended that 
diphtheria is always attended by prostration — laryngeal 
diphtheria need not be attended by any such evidence of 
debility from its beginning to its end. Such cases frequently 
terminate purely by broncho-pneumonia and asphyxia. 
The question of contagion, again, depends much upon the 
existence of epidemic disease — all sporadic cases being less 
prone to exhibit contagious properties. Thus, of symptoms, 
those of disordered innervation alone remain as distinguish- 
ing between one disease and the other, and these are not 
available for the purposes of diagnosis at the time when 
it is all-important to form an opinion. 

Some have taken up other ground, and have appealed to 
the local lesion to help them; and Oertel, admitting the ex- 
istence of two forms of membranous laryngitis, maintains 
that the presence of a profusion of micrococci in a mem- 
branous exudation is sufficient to determine against a sim- 
ple fibrinous inflammation, and even sufficient to allow one 
to predicate the speedy formation of membrane upon a part 



268 DISEASES OF CHILDREN. 

hitherto free. Dr. Goodhart hesitates to indorse such a 
statement, although it be backed by such a competent 
authority. It is better to teach that there are no certain 
histological differences which will allow us to distinguish 
by microscopic aid between a diphtheritic and a non-diph- 
theritic membranous laryngitis. There seem to be sufficient 
grounds for a belief in the existence of a non -diphtheritic 
as well =as of a diphtheritic membranous laryngitis ; but, 
inasmuch as it is admittedly impossible to distinguish readily 
and certainly in doubtful cases between the two, and the 
question of contagion is involved in the decision, it is best 
to consider all cases as diphtheritic, and to take precaution- 
ary measures in accordance with that assumption. 

Meigs and Pepper confess that, apart from sporadic cases, 
they are unable to detect any difference between pseudo- 
membranous croup and cases of so-called primary laryngeal 
diphtheria, when the angina is trifling, and is rapidly fol- 
lowed by the formation of pseudo-membrane in the larynx. 

J. Lewis Smith states that the diagnosis of diphtheria 
from membranous croup, though possibly in typical cases, 
in localities where diphtheria is not endemic or epidemic, is 
difficult, if not impossible, at the bedside, in localities where 
diphtheria prevails, especially when there is little or no exu- 
dation in the fauces. 

Ellis remarks that, "despite the high authorities who 
urge the identity of these diseases, I confess to remaining 
unconvinced." 

Scarlatina may be mistaken for diphtheria, but the points 
of distinction are numerous, and in well-marked cases 
should be decisive. The attack is sudden in onset, the py- 
rexia in like manner quickly attains a persistent altitude, 
the fauces are more generally reddened, and the strawberry 
tongue is present. There is none of the characteristic 
membrane. Albuminuria is a sequela, not an early symp- 



DIPHTHERIA. 269 

torn, and it is associated with dropsy and haematuria. 
Lastly, endocarditis and rheumatism may follow up scarla- 
tina. Endocarditis, however, is not an infrequent occur- 
rence in diphtheria. Its presence should influence the 
prognosis of the attack, and put us on guard against the 
development of chronic endocardial lesions and their accom- 
paniments. 

Heart-clot also sometimes occurs. It is most often de- 
veloped about the time that the patient enters upon con- 
valescence. 

In tonsillitis the onset is sudden ; the swelling great and 
cedematous ; often unilateral, without glandular enlarge- 
ment. It is not a very common disease in childhood, except 
in mild form, as part of the history of a chronic condition. 

Treatment. — Our present knowledge, which is derived in 
part from experiment, in part from the experience of the 
records of cases, teaches, as has been already said, that diph- 
theria is due to a germ, which effects a lodgment usually in 
the fauces or respiratory passages ; undergoes a process of 
incubation, and subsequently becomes generalized. This 
is the central point from which much of our treatment must 
be directed. Diphtheria is in great part a local disease, and 
is to be treated in great part by local measures. Unfortu- 
nately, the poison in some cases becomes very rapidly gen- 
eralized, and the child then suffers from a bad form of blood- 
poisoning, which deprives the local affection of its primary 
importance ; it must also be added, that hitherto local 
treatment has not been very successful. Thus, internal 
treatment being by no means unimportant, has, perhaps, in 
its more easy applicability, hindered the thorough persever- 
ance in local measures. But neither is the local treatment 
of ringworm very successful — certainly not if anything 
short of the most thorough measures be adopted ; neither 
is the local treatment of cancer very successful. But in 
23 



2/0 DISEASES OF CHILDREN. 

neither case are local measures discarded ; the whole ten- 
dency of modern teaching is to make our local treatment 
of these diseases more searching ; and so it must be with 
diphtheria. The parallel drawn between diphtheria and 
ringworm of the scalp is a particularly close one ; for both, 
according to present knowledge, are parasitic, and ringworm 
is acknowledged to be readily curable, so long as it is super- 
ficial, and does not dip into the hair follicles. A similar 
invasion of the follicles, and even deeper structures, is a 
leading feature of the resistance- of diphtheria to local 
measures. When superficial, it is easily kept at bay ; but 
when the whole surface, follicles and all, are stuffed with 
micrococci, the local treatment fails to arrest the growth, 
and the failure of what is — let us acknowledge it at once 
— a troublesome treatment, paralyzes our energies, and the 
growth of membrane conquers. Local treatment is trouble- 
some. It is easy enough to order the application of a spray 
to the throat ; it is easy enough to order the fauces to be 
swabbed with this or that gargle or lotion ; but orders of 
this kind usually result in some utterly ineffectual applica- 
tion. To keep diphtheritic membrane at bay, the application 
must be thorough, and it must be frequently repeated. This 
means a frequent disturbance of a child whose only want, 
perhaps, is to be let alone, and a thorough application of 
anything to the fauces means generally that the strong re- 
sistance of a struggling child has to be encountered — per- 
haps taking two people to hold it while a third attends to 
the throat — perhaps necessitating a gag ; and all this with 
an amount of sputtering, gasping, and choking from the 
irritation of the epiglottis and larynx, such as makes the 
parents recoil from it with dread, so that only the strongest 
determination and belief in the value of the means will 
enable the physician to persevere. No one who accepts the 
bacterial nature of the diphtheritic process, who clearly 



DIPHTHERIA. 27 I 

realizes the nooks and crannies of the throat and fauces in 
which membrane delights to grow, and the difficulties of 
management of unreasoning childhood, will have any diffi- 
culty in understanding why local treatment has often failed 
— why local treatment will often fail again. But this will 
not deter him from returning to the attack with all possible 
additional aids and suggestions, and whatever we may 
think of the nature of the disease, that treatment will, in 
the long run, be the most successful, which, while doing 
everything possible to support the child, is ever on the 
alert to combat the formation of membrane. 

For treatment, then, first and foremost, we place local 
applications, undeterred by the fact that they have often 
proved ineffectual, and of local measures, the application of 
antiseptics rather than escharotics is to be preferred. They 
must be repeated as often as membrane begins to form on the 
surface ; and since prevention is more easy than cure, what- 
ever local applications be adopted should be applied at 
regular intervals, until the chance of fresh formation of 
membrane be altogether past. The best plan to adopt is to 
detach and remove any membrane that can be reached, and 
then to paint the local application upon the diseased sur- 
face. This method is held by many most experienced men 
to be useless, or worse. It is harmful upon the ground 
that any injury to the mucous surfaces encourages the fresh 
formation of membrane. It is useless because the noxious 
germs composing the membrane have already passed beyond 
the reach of local applications into the lymphatics and blood- 
vessels beneath. Such reasoning is not convincing, and the 
want of success upon which it is founded is, as already 
shown, not altogether surprising. It is advisable to apply 
the local applications as gently as possible. The healthy 
mucous membrane should be in all cases respected. But 
the little bleeding that ensues upon detaching a thick flake 



272 DISEASES OF CHILDREN. 

of perhaps fetid membrane can surely be of little importance; 
and supposing that the membrane forms again, things are 
not worse than they were before. Of local applications 
many have been recommended. Dr. Goodhart prefers a 
saturated solution of borax with soda, or boracic acid in 
glycerine, the solution being made by the aid of a water bath ; 
or a solution of permanganate of potassium, twenty grains 
to the ounce ; or a ten-grain to the ounce solution of qui- 
nine, made by the aid of hydrochloric acid, in equal parts of 
glycerine and water. These are not unpleasant, the borax 
or boracic acid least of all so ; they are best applied by 
painting with a bent laryngeal camel-hair brush, but the 
application can, if it be preferred, be made by means of the 
hand spray — the nozzle being placed upon the tongue 
between the teeth, or passed through Dr. East's ingenious 
funnelled tongue depressor, and the pumping continued for 
a few seconds. The application must be repeated at least 
every two or three hours, sometimes every hour. Dr. Este's 
solution is a good one ; it is composed as follows : — 

R. Liniment, iodi (B. P.), rr\, xl 

Acidi carbolici, f 3 ij to fgiv 

Spt. vini rect., fjf ss 

Glycerine, ^E 1V 

Aquse, q. s. ad f ^ viij. M. 

SiG. — Apply to throat. 

This is used as a spray every hour until the throat 
begins to clear, and then every two hours or less often. 
Some cases do well with free dusting with sulphur. 

Other things have been recommended, such as perchloride 
of iron in glycerine, sulphurous acid in glycerine, solution 
of liq. sodae chlorinatae or chlorine water, carbolic acid, etc. ; 
these are all antiseptics or germicides, and are radical in their 
intention. Others are useful for dissolving the membrane, 
and of these lime-water and bicarbonate of sodium solution 



DIPHTHERIA. 273 

(20 grains to the ounce), and lactic acid, "Xxv to lime-water 
f 5j), used as spray, are at once effective and harmless. For 
the same object Dr. Hale White has proposed a solution of 
pepsin in glycerine, and this solution also has active solvent 
power. Papaine and trypsin are the latest remedies of this 
class. Jacobi recommends a watery solution of papaine, 
one part to twenty, and Dr. Goodhart has used this success- 
fully in several cases. The American editor prefers trypsin 
prepared according to the following formula : — 

R. Trypsin, gr. xxx 

Sodii bicarb., gr. x 

Aq. destillatse, f^j. M. 

SlG. — Apply with a brush or by sponging; use as frequently as practi- 
cable, three or four times in the first hour if conditions permit. 

For internal administration many experienced practi- 
tioners insist strongly upon the value — nay, even almost 
the necessity — of a preliminary aperient of calomel, fol- 
lowed, it may be, by some castor oil, if the mercurial is not 
sufficiently effective, after this the various drugs that have 
been recommended are too many even to recount. A 
chlorate of potassium or guaiacum lozenge may be given 
every three or four hours, or the citrate of iron and quinia 
may be given in glycerine, or chlorate of potassium and 
perchloride of iron in equal parts of glycerine and water. 

The following prescription, acting both locally and gen- 
erally, frequently produces excellent results : — 

U . Quinice sulphatis, gr. xij 

Potasbii chloratis, gr. xlviij 

Tinct. ferri chloridi, f^j 

Syrupi zingiberis, f 5jj 

Aquae, q. s. ad fj§ iij. M. 

SlG. — One teaspoonful, diluted, every two hours, for a child from six to 
ten years. 

Should the stomach revolt against quinine, either the sul- 
phate or bisulphate, in two to three grain doses, may be 



274 DISEASES OF CHILDREN. 

given in suppositories, every four or six hours, at the age of 
six years. In the preparation of these care must be taken 
to reduce the drug to an impalpable powder, lest local irri- 
tation be produced. Pilocarpin is a remedy that may be 
tried cautiously, as some good results have been obtained 
by its use. Lax, who has tried it, recommends a sixth of 
a grain or more to be given by the mouth in a watery solu- 
tion. But it is not a very safe remedy for young children, 
and bad results have followed its administration. 

Stimulants in free doses — as one teaspoonful of whiskey 
every hour — are called for in some instances. 

Cases of this kind should have plenty of fresh air, but be 
kept warm in bed, and the air should be kept charged with 
a moist disinfectant vapor. One of the best is the follow- 
ing : creasote, Sj, pulv. acacise, 3ij. The gum and creasote 
are rubbed up together, and added to two ounces of lotio 
acidi carbolici (i to 20). The whole is then put into a 
bronchitis kettle with a pint of water. A not unpleasant 
vapor is given off, distinctly different from either creasote 
or carbolic acid. A teaspoonful of terebene put into half a 
gallon of water makes another useful and not unpleasant 
inhalation ; but the 'terebene volatilizes rather quickly, and 
must therefore be frequently replenished. Sanitas also is a 
good and pleasant disinfectant. 

The food given must be of the strongest : milk, eggs, 
strong beef-tea, Brand's essence. If children refuse liquids, 
there is no particular objection to the administration of 
solids ; and for those who are difficult to tempt it may be 
advisable to try artificially digested foods, which are most 
temptingly administered in the form of jelly or blancmange. 
Alcohol also must in many cases be administered, and in 
large quantities ; two or three ounces of brandy in the course 
of the twenty-four hours. In the worst cases it may be 
advisable to try enemata ; but they are not borne long in 



DIPHTHERIA. 275 

children, as the rectum becomes irritable and expels them 
after one or two have been retained. Indeed, as else- 
where remarked, the failure of enemata induces me to 
resort to the passage of a soft catheter along the nares into 
the oesophagus, and food is introduced by this means into 
the stomach very satisfactorily. 

If a child is choking, it is obviously right to give it the 
further chance which opening the windpipe offers : no one 
will dispute this. The chance appears to vary in the expe- 
rience of different physicians, but probably Trousseau's 
original estimate of his own cases — one recovery in five — 
is about the average all round. Still there is no little diffi- 
culty in deciding this question, for there is probably no 
operation in surgery which requires so much the personal 
supervision of the surgeon as tracheotomy, and there can 
be few in which the degree of hope which may be indulged 
depends so much upon the after treatment. But it is the 
custom of the advocates of operation to argue that the 
mortality after tracheotomy is so great because the opera- 
tion is postponed till too late ; that the operation itself is 
not a serious one, but that it cannot be expected to succeed 
if performed when the disease has extended down the 
trachea, and that if performed early more success would 
attend it. Now first of all let us clearly understand what 
this means. It means that the trachea is to be opened 
before there is any immediate risk to life, and this is a very 
different thing to an operation which is the only chance left 
of life. But there can be no objection to an early operation 
if no extra risks are entailed by it, or if any extra risk is 
compensated by advantage gained, such as, e.g., if by 
operating early the formation of membrane can be arrested. 
Early operation has been defended chiefly upon the ground 
that the operation is not a serious one. Now in diphtheria 
it is serious. It is prima facie unreasonable to contend 



276 DISEASES OF CHILDREN. 

otherwise, if it be true, as many think, that even the mem- 
brane on the fauces should not be disturbed for fear of pro- 
voking fresh inflammation and formation of membrane ; and 
as a matter of fact, the operation of tracheotomy, when per- 
formed upon the diphtheritic child, is frequently followed 
by diffuse inflammation of the cellular tissue of the neck — 
the edges gape, and a large sloughy wound is formed, which 
becomes dry and fetid, and not unfrequently covered with 
membrane. But further, is it supposed that the mucous 
membrane of the trachea itself suffers no injury from the 
introduction of the tube ? The richness of the glandular 
and blood supply, and the sensitiveness of the mucous 
membrane to changes of temperature, make such a thing 
highly improbable, while it would be easy to show, in the 
clearest manner, by the evidence of the post-mortem room, 
that the operation itself, and the presence of a tube after- 
ward, are, in one way or another, fraught with danger. 
The broncho-pneumonia, the purulent bronchitis, the ex- 
cessive tracheitis, so often seen in fatal cases of diphtheria, 
are chargeable quite as much to the operation as to the 
original disease. The state of the trachea in fatal cases is 
not calculated to impress one favorably with the harmless- 
ness of tracheotomy ; but let that pass, for it may well be 
said that these are the hopeless cases, qua diphtheria. But 
even in others that do well the amount of mucus and muco- 
purulent discharge ejected from the tube, and the slowness 
with which this ceases, are sufficient to show that the mu- 
cous membrane of the trachea must in any case undergo 
grave alterations. For these reasons, among others, early 
tracheotomy in diphtheria must be advocated, not from its 
harmlessness, but upon other grounds. But hitherto these 
other grounds have been little appealed to in practice. The 
operation has been performed ; if happily the membrane 
failed to spread— well, but no thanks to treatment; the 



DIPHTHERIA. 277 

operation relieved a symptom and temporized while the 
disease spent itself. If death resulted it was only to be ex- 
pected of the disease ; the operation has taken no share of 
the responsibility. But if, on the other hand, we resort to 
an operation not immediately necessary, in the hope that by 
so doing, some local measures may be adopted which will 
help to combat the formation of membrane, the operation 
has another basis upon which it may stand, of a less assail- 
able nature. Upon this ground alone — that of the more 
thorough application of local remedies to the larynx — does 
an early operation admit of advocacy. Possibly on this 
ground the operation will yet justify itself and the addi- 
tional risk which it necessitates be more than counterbal- 
anced. It cannot be said that this is so at present ; and, 
although the author urges perseverance in local measures, 
he still thinks that the operation of opening the windpipe 
should be deferred to the latest possible limit. 

Tracheotomy, however, should not be too long delayed. 
It should be performed as soon as there are urgent symp- 
toms, and every preparation for the operation should be 
made beforehand, that no valuable time may be lost during 
it. The symptoms demanding operation are increasing 
dyspnoea, supra-sternal depression, well-marked retraction 
of the scrobiculus cordis, and lividity about the face and 
finger tips. 

When tracheotomy has been determined upon, the prin- 
ciple upon which success depends is to tamper with the 
tracheal mucous membrane as little as possible. To put a 
tube into the trachea and to leave it there, save for chang-ine 
it occasionally, is but to exchange the risk of choking for 
the more deadly one of diffuse and ulcerative tracheitis.. 
No doubt a certain sense of security is felt by the surgeon 
when a tube is safely in the throat, but it is dearly pur- 
chased for him by his patient, and the largest percentage of 
24 



278 DISEASES OF CHILDREN. 

successes will certainly be procured by dispensing with the 
tube as much as possible. But this treatment cannot be 
carried out without a trained nurse who is equal to remov- 
ing and re-inserting the tube, and who is also possessed of 
sufficient self-command to meet the still greater emergency 
of not being able to re-introduce it, when it will become 
necessary to keep the wound open by forceps until assist- 
ance can be procured. With a nurse of this kind, and the 
frequent supervision of the surgeon, one cannot doubt for a 
moment that the stated mortality can be, and has been, in 
the hands of individual operators, largely reduced. 

The operation itself is a surgical procedure, and it may 
perhaps be thought that the physician has no necessity and 
no right to speak upon that subject. Nevertheless, upon 
the principle that lookers-on see most of the game, we may 
venture to add some hints of importance for its due per- 
formance. 

The rules to be laid down for the conduct of opening the 
windpipe, are these : The operation should be as high as 
possible (1) because it may be necessary to deal locally with 
the formation of membrane in the larynx by means of the 
aperture, and this can be more effectively done when the 
operation is high than when it is low ; (2) because it is ad- 
visable to interfere as little as possible with the tracheal 
mucous membrane, and the connective tissue of the neck 
is less encroached upon in the incision. When the trachea 
is opened, the incision should be well separated by a dilator, 
and the parts thoroughly examined. This done, any mem- 
brane discovered either above or below it, is to be removed 
gently by a soft feather, and if necessary, an application 
may then be made to the larynx of a solution of boracic 
acid or borax in glycerine, either by a feather or the spray. 
The opening must be kept as free as possible, and the inte- 
rior of the windpipe tampered with as little as possible. 



DIPHTHERIA. 279 

The expulsion of membrane is thus favored, and the risk of 
extension of inflammation down the trachea is reduced to 
its minimum. To accomplish these objects some instru- 
ment, such as Golding-Bird's dilator, or Parker's automatic 
retractor, seem good in principle, although perhaps a metal 
tube as large as possible is more available for practice. 
This must be inserted for the first twenty-four hours. After 
this the aim is to do without any dilator or tube as much 
as possible. By this time any inequalities upon the sides 
of the incision which would be likely to hinder the easy 
re-introduction of the tube will have become sealed by 
lymph. Whatever the instrument employed it should be 
removed, the child being closely watched, so that it may be 
re-inserted when necessary. The time during which the 
dilator can be removed will vary much, sometimes not more 
than ten minutes can be allowed — sometimes half an hour, 
or an hour, or more : the more the better. Some cases have 
been treated successfully throughout without any tube, and 
Dr. Goodhart thinks this could be done more often and with 
much advantage to the patient. The tube is to be taken 
out several times daily, and kept out as long as possible, 
and after a day or two the metal tube is to be replaced by 
one of Mr. Morrant Baker's soft india-rubber tubes as short 
as possible. When the edges of the wound have consoli- 
dated, the curve of the tube may be removed, leaving a 
straight stump long enough to reach from the surface 
through the cedematous tissues to the trachea. So far as 
the nature of the material is concerned, the author believes 
it would be better to insert a soft rubber tube at once, but 
the objection to this is that the bore of these is smaller than 
that of the metal tubes, and for the first day or two it is of 
paramount importance that the aperture should be as free as 
possible. When the tube is removed or replaced, the op- 
portunity may be taken, if it be judged necessary, for apply- 



28o DISEASES OF CHILDREN. 

ing the boracic solution to the larynx. The trachea should 
only be treated in similar fashion if there be evidence that 
the membrane is extending downward. The application 
may be made by a feather or a laryngeal brush, or by a 
piece of sponge or cotton wool twisted into a loop of wire. 
If preferred/ a spray can be applied to larynx or trachea 
through the opening. It is not desirable to frequently 
feather the trachea for the removal of membrane, and prob- 
ably a free aperture best effects its expulsion ; but one of 
the risks attaching to the operation is the loss of expiratory 
power, which results from opening the trachea below the 
larynx, and this makes it necessary to be ever on the alert 
to remove membrane either by a feather or by the tracheal 
forceps, which must always be ready to hand. 

It may be further added as regards the final removal of 
the tube, that those only who have had experience of such 
cases know how difficult this often is. What the exact 
conditions in the trachea or larynx may be that render it 
so, are difficult to state, but it is often many days, and some- 
times weeks, before the tube can be altogether dispensed 
with. Perhaps the child will breathe well by day and badly 
by night, or will go without the tube completely for three 
or four hours and then have dyspnoea. In all these cases 
the short tube should, if possible, be worn, and the external 
aperture should be plugged as much as possible so as to 
compel breathing by the natural passages. As an alter- 
native to tracheotomy there is now the operation of intuba- 
tion, or that of passing a tube into the larynx per vias 
naturales, and retaining it there as long as may be neces- 
sary. Originally advocated by McEwen, the operation has 
been elaborated by O'Dwyer, who has devised an ingenious 
set of instruments for the purpose. The operation has been 
largely practiced in America, and has met with warm 
advocacy, as well as some detraction. Whether it will 



DIPHTHERIA. 28l 

ultimately take rank as a serviceable measure in cases of 
diphtheria is doubtful, but it may probably do so for cases 
of simple laryngitis and cedema. 

The creasote vapor has already been advised, and plenty 
of fresh warm air. Many recommend a steam tent, but, 
provided the cot is well fumigated by the moist vapor, this 
is hardly necessary, and it often makes the child hot and 
restless. 

There is yet the treatment of diphtheritic paralysis to be 
considered, and this may be both preventive and curative. 
It is of the utmost importance to remember that diphtheria 
is a disease which leads to great anaemia — great exhaustion ; 
and it is the opinion of many that if after diphtheria the 
child be confined to bed, kept quite free from excitement, 
and fed frequently, and so treated until the nutrition has 
been in some measure restored, and the anaemia curtailed, 
paralysis will but seldom occur. There can be no doubt 
that to be up and about in the early days of convalescence, 
feeling ill, but without anything definite the matter, is one 
of the surest incentives to its onset. It is also to be remem- 
bered that, like the albuminuria of scarlatina, the paralysis 
after diphtheria may follow such cases of indefinite disease, 
as the malaise and slight sore throats which so often run 
through a household when one of its members is attacked 
with the pronounced disease. 

When paralysis has come about, the same rules apply ; 
perfect rest in bed is the first necessity, together with the 
most nourishing food. This must be given at frequent 
intervals, and it is well to remember that in the paralysis of 
the throat solids are often better swallowed than liquids. 
It may be necessary to feed by means of a tube passed into 
the stomach, and probably the nasal tube will be more easy 
of application than the oral. Enemata may be also given 
and, in addition to the food, stimulants are valuable, and 



282 DISEASES OF CHILDREN. 

maltine and cream are good additions to the food. The 
greatest care and patience is requisite in feeding these cases 
lest they choke, or food pass into the larynx and trachea 
and set up a broncho-pneumonia. Most of the cases of 
localized faucial paralysis recover very slowly, and a great 
deal of inconvenience may be experienced for months — 
sometimes in swallowing, sometimes by difficulties in pho- 
nation ; those in which the affection is general are always 
tedious and often dangerous. The heart suffers and the 
respiratory muscles also ; the one becoming dilated, the 
others, by their sluggish and imperfect action, leading to 
collections of mucus in the bronchial tubes and so to bron- 
cho-pneumonia. These cases must be fed as others ; iron, 
quinine, strychnia, and arsenic must be administered, and 
the muscular system must be renovated by the movements 
of shampooing and by electricity. In paralysis of the heart 
in its worst forms the sudden fatal issue precludes all treat- 
ment ; but a careful watch upon the heart should be kept 
in all these cases for the earliest indications of dilatation of 
the ventricles. A careful administration of digitalis, or 
belladonna, iron, and stimulants may, in these cases, some- 
times be attended with successful results. 

6. Varicella. — The chief interest of chicken-pox lies in 
its resemblance to smallpox, and in the suggestions which 
come out of this resemblance. The relation of vaccina to 
variola and the different behavior of the latter when intro- 
duced by inoculation to that which it shows when operating 
upon virgin soil, under conditions of introduction, so to 
speak, of its own choosing, show how liable is variola to 
undergo modification. And when further we bear in mind 
the many points of resemblance which modified variola 
bears to varicella, the question irresistibly presents itself, is 
varicella modified smallpox ? To this the answer must be 
— No. For many reasons, but for this one above others — 



VARICELLA. 



283 



conclusive as it is considered for all exanthems — that vari- 
cella and variola may both occur within a short time of one 
another in the same person, and pursue an unmodified 
course. One of the most striking cases of this kind is 
recorded by Dr. Sharkey in the Lancet, vol. 11, 1877, p. 47. 
A boy, aged five, under Dr. Bristow, was admitted with 
varicella out upon him. Variola was rife at that time, and 

Fig. 5.* 



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TEMPERATURE CHARTS OF TWO CASES OF VARICELLA IN CHILDREN OF 
3^4 YEARS AND l8 MONTHS. 

existed in the block where the child was warded ; he was 
on this account vaccinated the third day after his admission, 
and took very well. Ten days after admission, the eighth 
day from vaccination, he became very ill, and the next day 
the variolous eruption appeared. Varicella does not there- 
fore protect from variola, nor does vaccina protect from 
varicella, and the germs are distinct. 



* From Ashby and Wright. 



284 DISEASES OF CHILDREN. 

Incubation. — This is variously stated to last from eight to 
sixteen days. Dr. Dukes, from some careful observations 
made at Rugby, makes it as long as fourteen to nineteen 
days ; the shortest incubation in fifteen cases being thirteen 
to fourteen days in one case, fourteen in two, fourteen or 
fifteen in one, fourteen to sixteen in two, fifteen in three, 
and the remainder more. It is attended by no definite 
symptoms ; but there may be slight malaise for a day or 
two before the outbreak of the eruption. 

The Eruptive Stage is generally associated with more or 
less pyrexia, loss of appetite and languor ; but the amount 
of constitutional disturbance may be, and usually is, very 
slight indeed. In unhealthy children the eruption may be 
copious and the resulting sores lingering in their course, 
and in such the illness may be considerable, and even fol- 
lowed by persistent anaemia, discharge from the ear, or 
some enlargement of glands ; but this is rather an outcome 
reserved for the squalid and forlorn than for the child of 
the well-to-do. It is also stated, and this is interesting 
when we remember the mortality which attends measles in 
native races, that the death rate is sometimes high in India 
among the ill-fed and badly clothed children of the native 
population. The eruption consists of oval or globular vesi- 
cles containing opalescent contents and situated upon a 
slightly inflamed base. The vesicles commence as a small 
red papule, the vesicle forming within a very few hours, 
while the amount of inflammation around it constitutes a 
measure of the severity of the disease and of the condition 
of the patient. In many cases there is no areola round the 
vesicle ; a small pearly bleb rises from an almost natural 
skin, and the appearance suggests that the child has been 
exposed to a shower of boiling water. In severe cases the 
zone of injection is vivid and considerable. The eruption 
comes out in crops, one crop quickly succeeding another, 



VARICELLA. 



285 



mostly on the back and abdomen, but also found on the 
face, scalp, and other parts, more rarely in the mouth. 
The vesicles form rapidly; they contain alkaline serum, 
which becomes a little turbid, in some cases purulent. In 
ordinary cases the vesicles shrivel within a day or two and 
leave a small dry scab. This falls off in another day or so 
and leaves behind a small pigmented stain, and occasionally- 
a slight scar. Mr. Hutchinson thinks that scars are not 
uncommon if carefully looked for; but this depends much 
upon the extent of local change. If the vesicles are rubbed 
or excoriated in any way — or if the vesicle ulcerates, as it 
may sometimes do, these scars will be found, but not other- 
wise. The crops of vesicles occasionally last six or eight 
days, but the disease is usually over within three or four 
days, or even sooner ; the crusts, however, adhere to the 
skin for some days longer. 

The disease occurs in quite young infants. Gee gives a 
table of 727 cases from the Ormond Street Hospital, with 
this result : — 



Under 1 month, 2 



2 months, 

3 " 
6 " 

12 " 

18 '< 



.... 8 

.... 13 

.... 57 

.... 97 

.... 62 

2 years, 75 

3 " 78 



Under 4 years, 100 



96 

58 
30 
29 
10 

5 

7 



It is not known to recur, and with one exception has no 
complications of importance and almost no sequelae. It 
may, however, be stated that the vesicles are attended with 
a good deal of irritation, and in the unhealthy children of 
hospital out-patient rooms, it is not uncommon to find 
somewhat persistent superficial ulcers, perhaps beneath 



286 DISEASES OF CHILDREN. 

scabs, for some time after the outbreak of the varicella. 
But when this is the case, the student should have it in 
mind that the original malady may have been pemphigus 
and not varicella at all. 

The exception alluded to is Varicella gangrenosa, of 
which several cases have been recorded, and which, if it 
may be considered as of several grades of severity, is, per- 
haps, not uncommon. Its mildest form is that just de- 
scribed, where persistent superficial ecthymatous sores re- 
main for some time after varicella. In the next grade — 
whence the disease derives a special name — the body is 
more or less covered with deep ulcers, which have a sharp 
angry-looking edge, and a black gangrenous crust within. 
The ulcer may be -evidently formed by confluent vesicles, 
and for this reason, as well as from the fact that he had 
found it repeatedly associated with varicella, Mr. Hutchin- 
son* was directed to what he believes to be, and what is now 
generally accepted as being, its real origin. Mr. Hutchin- 
son was further able to identify it as passing under other 
names, and he gives strong reasons for thinking that the 
so-called rupia escharotica as represented by some models 
in the museum of Guy's Hospital (Skin Series, 206, 209) 
are of this nature, as also an epidemic of " an eruptive dis- 
ease in children " described early in the present century by 
Dr. Whitely Stokes, of Dublin, and another described by 
Trousseau, and alluded to below. There is a still worse 
form than this, in which the gangrene is diffused and attacks 
a large part of one or both limbs, or a large surface of the 
trunk, and when, unless attention be called to the circum- 
stance, the affinities of the disease are still less likely to 
attract attention. A case of this sort has been put on 

* " Medico- Chir. Trans.," vol. lxv, p. 1. 



VARICELLA. 287 

record by Mr. Bellamy.* It might be thought that there 
is nothing peculiar in such an occurrence — that, given the 
preexistence of starvation and neglect, the outbreak of a 
pustular eruption such as this would be likely to engender 
an ecthyma — but it would appear that this explanation will 
not hold, for Mr. Hutchinson makes special note of the fact 
that the affected children were, some of them at any rate, 
vigorous and healthy. Dr. Payne has devoted attention to 
the point, and he suggests that possibly the existence of 
tubercle in the child may lead to the very severe manifesta- 
tion of chicken-pox. At any rate, tubercle has been found 
to be present in the bodies of most of the cases to which 
Dr. Payne has had access. f If this should seem insufficient, 
we must, for the present, fall back on Mr. Hutchinson's 
suggestion of special idiosyncrasy — or perhaps we may say 
that what rupia is to syphilis, cancrum oris to measles, 
vaccinia gangrenosa to vaccinia, as we shall presently relate, 
so gangrene is to some cases of varicella, a risk that it 
shares with other exanthems. 

Diagnosis — Modified variola causes the most difficulty. 
It will be well to bear in mind that varicella has no prodro- 
mal fever ; that the vesicles are not umbilicated, and collapse 
at once when pricked — in other words, they are simple, not 
multilocular, and that the eruption comes out in crops, and 
therefore exhibits stages upon the skin, while variola appears 
at once. With variola, varicella also stands contrasted by 
its brief invasion period, the short duration of its initial 
fever, the absence of secondary pyrexia, the difference in 
the position at which the surface lesion first appears, the 
larger size and softness of the papules and the rapid transi- 
tion of the phases of the eruption. There are several fea- 

* " Clin. Soc. Trans.," Vol. xx, p. 195. 

f " Trans. Path. Soc," Lond., Vol. xxxvi, p. 471. 



288 DISEASES OF CHILDREN. 

tures of smallpox, usually considered to be important 
distinctions between it and chicken-pox, that are of little 
diagnostic value, because, practically, they are common to 
both diseases. These are the appearance of the eruption on 
the scalp, its presence on the visible mucous membranes, 
umbilication of the vesicles, and pitting. 

The editor has often seen the eruption of varicella on the 
scalp, and in the majority of his cases a varying number of 
pseudo-membranous points were present on the mucous 
membrane of the cheeks and palate, differing from those of 
variola only by being larger and more yellow in color. 
Again, the vesicles are frequently umbilicated ; this occurs 
only in those that begin to desiccate in the centre, and on 
close inspection minute crusts can be detected in this posi- 
tion. Both the cause and appearance differ, therefore, from 
the variolous umbilication, but the likeness is close enough 
to confuse a superficial observer. 

Pitting, too, occurs where large vesicles are accidentally 
broken by scratching. It is usually seen on the face, 
and the scars, which rarely number more than three or 
four, are broader, shallower and smoother than those of 
variola. 

Pemphigus can hardly cause any difficulties, if the case 
be thoroughly inquired into, unless, indeed, we have to do 
with cases such as have been described ; by Mr. Hutchinson 
as persistent or relapsing varicella — where the disease 
may last as long as a month ; and by Trousseau, in which 
blebs like those of pemphigus come during fifteen to forty 
days, causing ulcerations like those of pemphigus, and 
which continue for six or eight weeks. 

Varicella has also occasionally to be distinguished from 
vesicular or pustular rashes following upon vaccination. 
Hebra says of them, that they resemble varicella. They 
are not very common. 



VARICELLA. 289 

Sequela. — Most writers would be inclined to say that 
there are no sequelae of varicella ; but superficial ecthyma- 
tous-looking sores are by no means uncommon in the 
hospital out-patient room. Mr. Hutchinson alludes fully 
to this condition, and how it may resemble pemphigus. 
Under the term varicella prurigo, adopted by him, are 
included not only the clearly vesicular rashes, which con- 
tinue after varicella, but also many of those papular prurigos 
which have hitherto been called lichen urticatus, lichen 
strophulus, etc. Mr. Hutchinson points out that many of 
these cases called lichen show abortive vesicles ; that they 
occur on the palms and soles, where no lichen can — seeing 
that it is a disease of the hair-follicles ; and that there is, in 
some cases at all events, a history, if not of origination in a 
recognized varicella, yet at any rate of definite onset at some 
particular date. Mr. Hutchinson seems, however, to adopt 
a view which Dr. Goodhart long believed, that in these cases 
it is hardly so much the disease which is at fault as the 
child; it is the fact of the occurrence of varicella — a disease 
which is apt to start a chronic itching — in a pruriginous skin 
(not uncommonly an inherited weakness), which entails such 
disagreeable results upon the child. Dr. Goodhart cannot 
doubt that these cases are identical with the disease called 
strophulus, the abortive vesicles and the occurrence of 
papules in the palms and soles notwithstanding ; and he adds 
that Dr. Hilton Fagge's opinion supports his own. Dr. 
Fagge writes of varicella prurigo : " I believe it to be an 
exaggerated form of strophulus." * 

Treatment. — Varicella very seldom requires any treat- 
ment. At the most some simple saline, a mild aperient, 
and a little vaseline to relieve the local irritation of particular 
spots, are all that are necessary. Varicella gangrenosa in 

* " Principles and Practice of Medicine," vol. ij p. 236. 



29O DISEASES OF CHILDREN. 

its severer forms is too often fatal. The sores should be 
kept clean, and dressed with carbolic oil or mild nitrate of 
mercury or boric acid ointment, and quinine, iron, and alco- 
hol given as medicine. 

7. Vaccinia. — Among the ignorant a large number of 
cutaneous affections are attributed to vaccination. If asser- 
tions of this kind are traced to their source, many have no 
foundation in fact, yet some' have — and it is well not to 
discredit such tales too readily. It can hardly be that the 
introduction of a material such as vaccine into the system 
never proves detrimental, and unquestionably, from time to 
time, vaccination is followed by various forms of cutaneous 
eruption. The risk of such an occurrence is as little to the 
individual as the gain to the community is great from the 
practice ; but the occasional occurrence of such a result is 
an incentive to the exercise of the most scrupulous care in 
vaccinating only such infants as appear healthy, and in 
selecting only such lymph as is absolutely pure. 

Much has been heard of late of the introduction of the 
syphilitic virus by means of vaccine, and it cannot be 
doubted that such a thing may occasionally happen, but 
its exceeding rarity, while it should serve to ensure the 
strictest precautions, may very well be used as an argu- 
ment in favor of vaccination rather than one against it. 

A short synopsis of the symptoms of the typical vaccine 
disease seems proper. 

Local Symptoms and Course of the Sore. — Usually on the 
third day a small hardened nodule of faint-red color appears 
at the seat of introduction of the virus. A serous exudation 
now raises the cuticle, and a vesicle is formed which by the 
sixth day begins to be depressed in the centre, or umbili- 
cated, and at the same time is surrounded by a narrow ring 
of inflammation. The vesicle increases in size, and reaches 
perfection by the eighth or ninth day ; it then projects above 



VACCINIA. 29I 

the surrounding surface, has a dull white color, and is about 
one-third of an inch in diameter. The narrow inflamma- 
tory zone has now extended so as to become a broad areola 
as much as two inches in breadth, of a scarlet, rose, or dark- 
red hue, the color gradually fading from the centre to the 
periphery where it shades into that of the normal skin. 
Coincident with the surface inflammation the subjacent con- 
nective tissue becomes infiltrated, hard, tender, and painful. 
By the tenth day the inflammatory symptoms have reached 
their height. The areola now rapidly fades and the vesicle 
loses the pearly appearance — pus taking the place of lymph 
and giving its characteristic color to the sore. By the four- 
teenth day the inflammation has subsided, the pus has 
become inspissated and the crust begins to form. This be- 
comes harder and darker in color, and falls by the end of 
the third week. The resultant scar is of a deep red or 
purple color, but in the course of from three months to a 
year should become smaller in diameter and present a 
smooth shining surface marked by pin-point depressions or 
radiating lines. 

General Symptoms are seldom present before the eighth 
day, when the child may become fretful, with fever, dis- 
turbed sleep, restlessness and partial anorexia. The 
accompanying (Fig. 6) is a chart of the ordinary tempera- 
ture range : — 

A variety of vaccine disease called vaccinia gangrenosa is 
a rare but very grave condition. We are indebted to Mr. 
Hutchinson for our knowledge of it, as we are for that of 
its varicellar congener. It is quite similar, in the appearance 
of the gangrenous patches, to varicella gangrenosa, and to 
the description of that disease the reader may refer. Dr. 
Goodhart adds that vaccinia gangrenosa is also — like vari- 
cella gangrenosa — a term to which some latitude must be 
allowed ; he takes it to be a label for a group of cases, the 



292 



DISEASES OF CHILDREN. 



individual items of which vary considerably. In the few 
cases seen by Dr. Goodhart, the history runs thus : that 
the child was born quite healthy, and so remained until 
vaccination. The vaccine inflammation was perhaps severe, 
and the ulceration of the vesicles considerable, and after 
they had healed crops of vesicles began to appear, and con- 
tinued to come out on and off for several months in all 
parts of the body. The vesicles turned to pustules, and 



Fig 6. 



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TEMPERATURE CHART OF VACCINIA. 



then to small sharp-edged ulcers with inflamed margins, 
which healed slowly, leaving a depressed scar. Mr. Lucas 
had a case under notice where the gangrenous patch was a 
large one, at the seat of the inoculation. 

Vaccination. — The introduction of vaccine virus into the 
system is effected in several ways — by incisions or scarifica- 
tion, puncture and abrasion. 



VACCINATION. 293 

The virus employed may be contained either in lymph 
directly from the vesicle ; the dried vaccine crust powdered 
and suspended in water ; or the lymph from cow-pox. 

Scarification consists in making four or five parallel inci- 
sions about a line apart and intersecting these with the 
same number at right angles. Should blood flow one must 
wait till this stops and there is but an oozing of serum, be- 
fore the virus is rubbed in. 

The puncture method consists in making a horizontal 
pocket in the true derm with the point of a lancet, in the 
groove of which is the virus. The puncture is then closed 
with isinglass plaster. 

Abrasion is the preferable method. The skin is made 
tense between the thumb and forefinger of the left hand, 
while with a gum lancet, which has no points to catch or 
cut the skin, the epidermis is quickly removed by a rapid 
but gentle scraping movement until serum slightly tinged 
with blood exudes from the true derm. The virus is then 
applied. Whatever form may be used must be well rubbed 
in and the part left exposed until the exuded serum, which 
contains the bulk of the virus, dries. 

Vaccinating from arm to arm, taking the lymph directly 
from the vesicle, is not very frequently done now, and is not 
to be recommended. 

When a crust is used, the central part only should be 
taken, as the margin is apt to contain blood, and may be 
the means of conveying disease. The part employed should 
be rubbed into a powder and dissolved in water. The crust 
is not often used in America, its employment being limited 
to cases that are unsusceptible to bovine virus and in those 
that have been directly exposed to contagion. It is used 
in the latter class because it " takes," and is therefore pro- 
tective, a day or two sooner than the bovine virus. The 
25 



294 DISEASES OF CHILDREN. 

purity of the source of this virus must always be a matter 
of careful consideration. 

Fresh bovine lymph on quills or ivory points can be ob- 
tained at any time in almost all large cities, and is much to 
be preferred as it does away with the possibility of the pa- 
tient becoming inoculated with any foreign poison. When 
applied the points or quills are moistened with clean water 
and the virus is well rubbed into the abrasion. 

The age considered most suitable to perform the opera- 
tion in infants is from the fourth to the twelfth month, 
though it is very common to vaccinate about the fourth 
week, before the monthly nurse is discharged. 

It seems important that the operation be performed early, 
as statistics show that in England nearly one-fourth of the 
mortality from smallpox occurs during the first year of 
life. Should an epidemic be prevalent the child should be 
vaccinated within the first twenty-four hours. The point 
selected for inoculation is usually the left arm, over the in- 
sertion of the deltoid muscle, but the leg is to be preferred, 
the choice position being beneath the knee and on the out- 
side of the limb, just below the junction of the tibia and 
fibula. In this site the sore is less apt to be irritated than 
at any other part of the body ; there is no tight-fitting gar- 
ment as there is about the arm, the diaper does not come 
within two inches of it, and besides the lymphatics are less 
apt to sympathize. The part, too, is easy to get at, and 
where the abrasion method is employed the operation can 
frequently be completed on a sleeping child without its 
being aroused. The number of points of insertion does not 
seem important so that the system be thoroughly impressed. 
Of this we can feel pretty sure from the character of the 
sore and the resultant scar. If later in life revaccination is 
performed, almost a positive immunity from smallpox can 
be assured. 



PAROTITIS. 295 

8. Parotitis (Mumps). — Inflammation of the parotid 
occurs under two sets of circumstances. In the one, it is 
secondary to typhoid fever, scarlatina, measles, etc., when 
it usually ends in suppuration; in the other, it is a primary, 
acute, epidemic and contagious disorder. With the latter 
we have alone to do now. Mumps appears to be looked at 
askance by writers on specific fevers. Like whooping- 
cough it has such definite local symptoms that there is 
reason for treating of it as a disease of the part which is 
specially concerned. But, inasmuch as it occurs in epi- 
demics, is very contagious, while a second attack is exceed^ 
ingly rare, there seems very little ground for excluding it 
from specific diseases. 

Etiology. — Although there are some who doubt it, the 
infectious nature of mumps seems to be indisputable. It is 
now only necessary to add that, although the disease is 
communicated by germs, it is not necessary to take any 
special precautions for the isolation of the affected children. 
The disease is so mild and so free from sequelae, that it can 
seldom be worth while to enforce any strict quarantine. 
Delicate children should naturally be protected as far as 
may be, and possibly boys when they are attaining to the 
age of puberty. It is certainly advisable to avoid all risk 
of orchitis. 

Incubation. — This extends over a period of fourteen to 
twenty-five days, according to Dr. Dukes' observations. 
He gives fifty-seven cases of mumps; fifteen of these were 
not available for the purpose of drawing conclusions. In 
the other forty-two the incubating period was from sixteen 
to twenty days in thirty, and possibly in thirty-four. Like 
most other specific fevers, the period of incubation certainly 
varies. In a family which Dr. Goodhart himself observed, 
a little girl incubated for fourteen days after coming in con- 
tact* with a child with mumps. The next child took it 



296 DISEASES OF CHILDREN. 

twenty-one days later, and the third twenty-one days 
later still. Henoch gives the stage of incubation as 
about fourteen days. Ringer says eight to twenty-two 
days. 

Symptoms of Attack. — The disease is attended with con- 
siderable malaise rather than with downright illness. The 
child looks very pale, and — on one side or the other, per- 
haps on both, often commencing on one side (the left, so 
it is said, more commonly) and extending to the other — 
there is a tender swelling which occupies the parotid region 
behind the angle of the jaw, and spreads over the side of 
the face in the situation of the socia parotidis. Generally, 
the color of the skin is not altered ; but occasionally there 
may be some redness over the parotid. There is a dull, 
aching pain when the masticatory muscles are moved. The 
temperature may be a little raised, but in many cases it 
remains normal. The swelling lasts for four or five days, 
and then gradually subsides. As regards constitutional 
disturbance, there is some variety. The fever may be con- 
siderable (103 ) for a short time; Dr. Gee has recorded one 
case of onset with convulsions, and there may be some 
delirium at night. As regards the swelling, it is not by 
any means always confined to the parotid ; it extends to 
the submaxillary gland, and also to the cervical lymphatic 
glands, and may sometimes even be confined to the latter, 
in which case the disease is likely to be mistaken. Occa- 
sionally the swelling is so great as to extend from one side 
to the other in a huge continuous double chin. When the 
disease is severe, the difficulty of deglutition is considerable, 
and, the child breathing with its mouth open, the tongue 
may thus become brown and dry. This is a point which 
it is important to remember, for the symptom is one which 
might otherwise lead us to regard the case with greater 
anxiety than need be. 



PAROTITIS. 297 

The duration of the disease is very variable ; five or six 
days appears to be about the usual limit ; its course, how- 
ever, may be protracted, for it sometimes happens that when 
the swelling has subsided on one side, it recommences on 
the other, and in this manner ten or fourteen days may be 
occupied. 

Complications. — Chief of these is the tendency, a rare 
one, in males to the occurrence of orchitis. It is often 
spoken of as a metastasis ; and I do not know that there is 
any objection to the term, inasmuch as the testis usually 
becomes affected as the parotid swelling subsides, although 
the two regions may be affected concurrently. Dr. Dukes 
gives twelve cases in boys; in six the orchitis began on the 
seventh day; in four on the eighth; with one on the ninth; 
and one on the first. The body of the testis becomes 
suddenly swollen and intensely painful, and the fluid often 
collects in the tunica vaginalis. The accompanying consti- 
tutional disturbance is generally severe, there being high 
fever and perhaps considerable delirium. All writers record 
the occasional occurrence also of an homologous affection 
of ovaries and mammae; but it is probable that this is one 
of the statements which is copied from book to book, and 
is far more imaginary than real. The occurrence of orchitis 
in mumps is rare ; indeed, it is a disease of adolescents 
rather than of children. Dr. West has no personal experi- 
ence of it, and Dr. Dukes considers that it comes only to 
those who have arrived at or beyond the age of puberty. 
Dr. Goodhart, however, has seen a very severe case in a 
boy of about twelve. He came under his care some years 
ago. 

The orchitis usually subsides within a few days ; but it 
may, on the other hand, lead to persistent hydrocele and 
atrophy of the testis. 

The appearance of orchitis at the date on which the 



298 DISEASES OF CHILDREN. 

parotitis naturally begins to disappear, tends to support 
Niemeyer's view, that the two affections are in reality due 
to the same cause, and that there is no true transference 
of inflammation from the parotid to the testicle. The right 
testicle is more frequently affected. The inflammation and 
swelling increase for from three to six days, after which 
resolution is rapid and generally complete by the end of 
the second week. The general symptoms are somewhat 
more intense than during the mumps, and, if the orchitis 
be bilateral, they are still more severe, and the course of 
the disease is slightly prolonged. 

Meningitis is another complication described as occurring 
but which must be very rare. Possibly a similar remark 
applies to this as to ovaritis and mastitis ; and it is not 
unlikely that the severe delirium which occasionally 
presents itself in the course of the testicular — and even 
sometimes of the parotid — inflammation may by some 
have been considered evidence of meningeal inflammation. 

Sequela. — A chronic induration of the gland is sometimes 
left after the attack ; but it is of little consequence, and usu- 
ally cures itself in the lapse of time. Suppuration of the 
gland is an occasional but rare sequela. 

Morbid Anatomy. — Practically none. Virchow has con- 
tended that the disease is a catarrhal affection of the ducts 
of the parotid gland, and Bamberger states the whole gland 
to be enlarged, red, and oedematous from interstitial exuda- 
tion. This is, indeed, highly probable, but facts to corrobo- 
rate it are very few. 

The exact-pathological lesion is obscure, on account of 
the rarity of opportunity for post-mortem examination. 
Foerster states that the affected gland first becomes hyper- 
aemic, and is then the seat of serous exudation. It is 
reddened, swollen, and on section presents a uniform, 
flesh-like, moist appearance, in place of the ordinary 



PAROTITIS. 299 

granular surface. The tumor is often greatly increased 
in size by a simultaneous serous infiltration of the peri- 
glandular connective tissue ; occasionally, this tissue alone 
is involved. The rapid and complete disappearance of 
the glandular swelling by the process of resolution favors 
this view. 

Diagnosis. — One can imagine that in young children the 
sudden and rapid swelling of the cervical glands from scar- 
latinal or diphtheritic poison might cause some doubt. But 
the extreme illness in the one and the less serious state in 
the other will ere long settle the doubt. On the other hand, 
the fact that mumps may show itself as an affection of the 
submaxillary gland or even of the cervical lymphatic glands, 
and leave the parotid untouched — though such cases are 
rare — is worth remembering. Lastly, the occurrence of 
suppuration should make one suspect and examine for some 
septic state other than that which hypothetically we suppose 
to be present in an attack of uncomplicated mumps. Atten- 
tion may be called to the throwing out of the lobe of the 
ear on the affected side at the commencement of mumps. 
This, when attention is called to it, is very striking, and is 
observed in no other affection. 

Treatment. — The disease is so mild, and so free from 
sequelae, that it may be a question whether it is worth while 
to enforce any strict quarantine ; but delicate children should 
naturally be protected as far as may be, and boys when they 
are attaining to the age of puberty. It is certainly advisable 
to avoid all risk of orchitis. As regards returning to school, 
four weeks should elapse from the commencement of the 
illness, if all swelling has subsided. When a child has been 
in contact with the sick, he should be isolated for a like 
period, the incubation being a lengthy one. It often hap- 
pens that no medical treatment is required. The child is 



300 DISEASES OF CHILDREN. 

kept warm in one room, and its diet is made to conform to 
its inability to masticate — to consist, that is to say, of 
milk, broth, jellies and blanc-mange. Should there be 
much fever, a drink may be made of a pint of barley- 
water, to which fifteen or twenty grains of nitrate of 
potassium, and the same quantity of bitartrate, are added. 

The local pain may be relieved by warm moist appli- 
cations, such as spongio-piline wrung out of hot water, 
or by lint soaked in warm water and covered with oil-silk. 
Chloroform or belladonna may be sprinkled on these, 
if necessary. Small doses of Dover's powder are also 
sometimes necessary. If the fever be severe, a drop 
of tincture of aconite may be given every hour for a 
few hours. 

The child is to be kept indoors for nine or ten days, and 
some tonic, such as Parrish's food, may be given afterward. 
In older children of the male sex and adolescents, particu- 
larly the latter — for the older the boy the more likely is 
there to be orchitis — the child must be kept in bed for eight 
or nine days, and the temperature carefully watched. Dr. 
Dukes has found that a rise of temperature is a good 
premonitory warning of the occurrence of this complica- 
tion, and that the early application of poultices to the 
part mitigates the pain and lessens the severity of the 
affection. 

It has been asserted of late that jaborandi and its alka- 
loid pilocarpine have the power of arresting mumps if given 
sufficiently early. We have not had any personal experi- 
ence of this ; but it is worth a trial, always remembering 
that pilocarpine in children sometimes acts as a powerful 
depressant, and should therefore be given with caution. 
Dr. Goodhart has given it in acute nephritis to the extent 
of one-fifteenth up to one-tenth of a grain as a subcutane- 



PERTUSSIS. 3d 

ous injection at the age of ten and twelve years, and from 
the slight effect produced by the lesser dose this might 
safely be given to children of six or eight years. It can 
also be given by mouth, and perhaps preferably so, one- 
eighth to one-fourth of a grain for a dose in a little syrup 
and water. 

In the violent delirium which occasionally happens, it is 
best to trust to saline aperients and warm baths. 

The orchitis requires plenty of warmth in the way of 
fomentations and baths, while the fever is treated either by 
aconite or saline diaphoretics. The urgent symptoms are 
not usually of any duration. 

9. Pertussis (Whooping-cough). — Like mumps, it is 
always a question with writers whether this disease shall 
be placed with specific diseases or with those affecting the 
parts or organs with which the symptoms more particu- 
larly concern themselves ; but surely, if the disease is 
specific and possesses infective properties, the most im- 
portant feature as regards the community is its specific 
nature — as regards the individual only, can the local symp- 
toms claim priority. Since, therefore, the well-being of the 
community is of the first importance, pertussis, most 
properly groups with those other diseases having con- 
tagious properties ; and, indeed, more fitly does it take 
this place than some others, for next to scarlatina it has 
the highest mortality of all the diseases of children. 

Incubation. — Dr. Goodhart states that in a family of two 
sisters it appeared to be eight days, the one being exposed 
to infection, and a cough beginning eight days after, the 
other following suit eight days later. Others state it to be 
from four days to a fortnight. Murchison quotes three 
cases upon the authority of Bristowe, which are almost free 
from the possibility of error, and which give a period of 
26 



302 DISEASES OF CHILDREN. 

incubation of fourteen days.* These cases are so well told, 
and the information is so precise, that they are quoted as 
reported : — 

"In the winter of 1874-5, Dr. B.'s three youngest chil- 
dren, owing to having suffered from severe ' colds ' in the 
previous autumn, were kept in the house in London from 
the early part of December until May, when the following 
occurrence took place : They were then in perfectly good 
health, and for several months had seen no children nor 
visitors of any sort. But at that time some nephews and 
nieces of Dr. B. were ill at Sydenham with whooping-cough. 
On Saturday Dr. and Mrs. B. went to dine with his mother, 
who also resided at Sydenham Hill ; and, on arriving, they 
found the eldest boy of the family referred to, living with her. 
He had hitherto escaped the disease, and was living with his 
grandmother in the hope that he might escape it altogether; 
but on this very Saturday he had, for the first time, a con- 
stant troublesome cough. Mrs. B., being afraid on account 
of her own "children, and believing that the boy was in the 
early stage of whooping-cough, did all she could to avoid 
him ; but he clung to her the whole evening, climbing on 
her knee, and coughing and sneezing over her. When she 
got home at night she took off her dress and laid it over an 
ottoman under a window in the dressing-room, intending 
next morning to have it hung out in the open air. Unfor- 
tunately, however, the eldest of the three children referred 
to came into the dressing-room early next morning, and 
began playing at the window over the dress. As soon as 
this was noticed she was sent away, and the dress was car- 
ried out of doors. Exactly thirteen days afterward, on the 



* Observations on the Period of Incubation of Scarlet Fever, and of some 
other Diseases: "Trans. Clin. Soc," vol. xi. 



PERTUSSIS. 303 

Saturday, this little girl appeared to have caught a bad cold, 
and ten days later she began to whoop. The two youngest 
children caught the disease from her, and both sickened 
about a fortnight after she first showed signs of illness. The 
seven other children in the family escaped, but they had 
had whooping-cough before." 

Probably here, as in other infective diseases, the incubative 
stage is a variable one, depending upon conditions, both 
atmospheric and individual, under which the poison or 
germ is cultivated. 

Symptoms. — The disease has almost always been described 
as one of three stages, but there is no true third stage. 
There is a primary stage of catarrh and fever, and a second 
of the paroxysmal cough ; but for a third, it is necessary to 
fix an arbitrary limit where the disease does not define any. 
The distinction between the two stages is of importance, not 
only because of its clear definition, but because the reme- 
dies applicable in the second stage are harmful in the first. 

In the first stage, which lasts a week or ten days, the 
child is poorly, with moderate pyrexia and a hoarse, dry 
cough, sometimes with a peculiarity of timbre which has 
been called ringing. As with other febrile conditions, the 
child may be pretty well during the day, with good appe- 
tite, or have its fits of fretfulness and cough, with loss of 
appetite. Probably the more or less of these symptoms 
depends upon the extent to which the fever runs. Auscul- 
tation at this stage usually reveals more or less bronchitis 
of the larger tubes, indicated by moist and dry bronchial 
rales, but there is little or no visible secretion from the 
bronchial tubes. As the catarrhal stage proceeds, the cough 
becomes more noisy and paroxysmal, with nocturnal exacer- 
bations, and the face a little full-looking with the eyes 
suffused, an appearance which to a careful observer may 
suggest what is coming. The whoop, the characteristic of 



304 DISEASES OF CHILDREN. 

the second stage, appears toward the end of the second 
week. As the author has watched it mostly in severe 
cases, and with the child in bed, the onset of a paroxysm 
has been quite sudden, a short series of rapid expiratory 
coughs ; but, should the child be up and about, it often 
becomes restless for some few seconds or minutes before, 
and may even run to its nurse or mother for support. 
But, from some observations which Dr. Newnham made 
in the whooping-cough ward of the Evelina Hospital, it 
appears that in some it begins thus, and in others with a 
deep inspiration. In either case the first expiratory part 
is short, and followed by a short whoop, to be quickly suc- 
ceeded by a longer series of similar short expiratory efforts 
to those at the onset, and a second and longer whoop, when 
the paroxysms may be over, or a third and a fourth may 
succeed, until the child is fairly exhausted. The paroxysm, 
short or long, terminates by a flatulent eructation and vomit- 
ing — a quantity of stringy mucus and food being ejected, 
often mixed with a little bright blood. The frequent repe- 
tition of the cough produces, in many cases, a characteristic 
appearance of face, which cannot be mistaken; the features 
are swollen or puffy, and dusky in color, not unlike, so far 
as the tinge is concerned, the aspect of a case of typhus. 
The eyes are watery-looking, and dusky in like manner, an 
appearance due, as is the color of the skin, to numerous 
minute ecchymoses or congestions of the smaller capillaries. 
In many cases there are extravasations of blood beneath the 
conjunctiva, which, of course, hardly admit of mistake. If 
examined during this stage, the chest has little to tell, pro- 
vided there is no broncho-pneumonia — a few rales, dry or 
moist, may be heard here and there, nothing more. The 
spasmodic stage of whooping-cough has no definite dura- 
tion, and varies much in intensity. In severe cases there 
may be twenty to thirty paroxysms in the course of the 



PERTUSSIS. 305 

twenty-four hours, or even more. At the Evelina Hospital, 
where all cases are recorded upon a chart, it is found that 
some paroxysms are accompanied by a whoop ; some are 
not; and that sometimes one, sometimes the other, kind pre- 
dominate. A typical case, one would suppose, should show 
an onset of the paroxysms without whoop, gradually lessen- 
ing in number; paroxysms with whoop to replace them; 
these again gradually declining and being replaced by a 
gradually lessening paroxysmal cough without whoop. 
But, as a matter of fact, it can hardly be said that this is 
so, the varieties are so many. Very young children often 
do not whoop. It is sufficient to know that they have fits 
of coughing, followed by sickness, and usually with some 
puffiness under the eyes. Children who are very ill with 
broncho-pneumonia often do not whoop; and in the declin- 
ing stage, there is much of habit in the paroxysmal nature 
of the cough, so much so that, as is well known, it is con- 
stantly happening, months after the cessation of the cough, 
it returns again, perhaps more than once, with nearly charac- 
teristic features, under the stimulus of some perfectly neutral 
catarrh. 

As regards the nature of the whoop there has, at one 
time or another, been much discussion, but it appears to 
me that too much attention has been paid to it. The whoop 
is the natural consequence of the paroxysmal cough, and 
is probably facilitated by the flexibility of the laryngeal car- 
tilages in young life. The nearest approach to the cough 
of whooping-cough is the sudden paroxysm induced by 
food (usually fluid) getting into the rima glottidis. We 
have there the remarkably sudden onset of a number of 
rapidly succeeding expiratory efforts, till the face becomes 
turgid, the eyeballs almost starting, and the eyes run with 
tears. In some cases a mild whoop is not uncommon, and 
is clearly then the sound produced by the influx of air 



306 DISEASES OF CHILDREN. 

through parts which are not ready to allow it to pass 
easily. Whether they are actually in a state of spasm 
seems to me to be doubtful — all that seems requisite ap- 
pears to be some want of harmony in the laryngeal muscles 
such as would produce at any rate a relative incapacity in 
the size of the conduit to the thoracic cavity, which needs, 
having been emptied to an extraordinary degree, to be filled 
with more than usual rapidity. There is also another class 
of cases which bears upon the whoop — viz., such as fre- 
quently make an inspiratory crow. There are some babies 
who, under the stimulus of any sudden excitement, such as 
waking from sleep, or suddenly being carried from a warm 
room to cold air, have a well-marked inspiratory crow, not 
so noisy as in pertussis, but.still surely of like nature. This 
condition is one incidental to the infant larynx in a certain 
proportion of cases, for it occurs in perfectly healthy chil- 
dren, goes on for many months, and then disappears. It 
may be due to an unusual flexibility of the cartilage, by 
which, under the call of sudden and deep inspiration, the 
membranes covering them are allowed to close in and 
partially to restrict the entrance of air. Dr. Lees has lately 
shown the state of the parts in such a case after death, and 
though practically the explanation holds good, for the 
mechanism is the same, the actual condition demonstrated 
is an excessively incurved epiglottis by which the ary-epi- 
glottic folds are so approximated as to form a mere chink. 

Spasm may well aid in accentuating the relative incapacity 
of the rima for the demand which is made upon it to admit 
an excessive supply of air in a given time ; it is doubtful if 
the existence of spasm is a necessity for the production of 
the whoop. From this it follows that the essential of the 
disease is not the whoop, but the rapid series of expiratory 
coughs, or the stimulus by which this discharging force is 
set going. 



PERTUSSIS. 



307 






The expulsion of a quantity of ropy, tenacious mucus at 
the end of the paroxysm of coughing is also an essential 
feature of the paroxysm. 

As regards other symptoms, it will only be necessary to 
allude to the statements that have been made concerning 
ulceration of the fraenum linguae, and increase of dullness 
over the root of the lungs and behind the sternum, as indi- 
cative of enlargement of the bronchial glands. Neither is 
of any real help, the ulceration of the fraenum occurring 
chiefly in cases where the character of the cough leaves no 
doubt, and the existence of abnormal dullness in the regions 
indicated being, according to Dr. Goodhart's experience, 
and he has made a frequent practice of testing the state- 
ment, exceedingly rare and equivocal. Whooping-cough, 
if of any ordinary severity, is usually accompanied by 
wasting, and in bad cases the emaciation is sometimes 
excessive. 

The duration of the disease is very variable, six to eight 
weeks is said to be the usual time. Of 126 of the author's 
cases, those lasting three weeks number 7 ; four weeks, 15 ; 
five, 6; six, 13; seven, 12; eight, 16; nine, 8; ten, 13; 
eleven, 4; twelve, 12; and those over twelve weeks up to 
twenty numbered twenty in all. 

The age at which it most often occurs is between two and 
six years, the exact figures in 314 cases being: — 



3 months 


and under 


6 


< (< 


1 year 


" 


2 years 


(« 


3 " 


i< 


4 " 


" 


5 " 


<( 



9 
23 
30 
60 
60 
54 
38 



6 years and under, 27 

7 " " 7 

8 " " 2 

9 " " 3 

10 " " 1 

Total, 314 



The mortality amounted to twenty-four males and six- 
teen females, a total of forty of the 314, or about 12 per 



308 DISEASES OF CHILDREN. 

cent. ; but this is really too high, because it includes all 
cases, whether in-patients or out-patients, and of the in- 
patients naturally the larger proportion are severe cases 
with much broncho-pneumonia. If the two classes of cases 
be separated the mortality among the in-patients rises to 
40 per cent., that among the out-patients falls to 9 per 
cent. The ages of the fatal cases well illustrate the rule 
that the younger the child the greater the risk. Ten were 
under six months old, four others under a year, twelve be- 
tween one and two years, seven from two to three, four 
from three to four, two from four to five, one child died at 
nine and a half, of a very lingering broncho-pneumonia, 
probably of destructive nature. Thus in thirty-three out 
of forty deaths the children were under three years of age. 
As regards the causes of death, five-and-twenty died of 
broncho-pneumonia ; in three of the cases convulsions were 
superadded ; six others had convulsions ; the remaining 
nine died under various conditions, of which Dr. Goodhart 
notes a drowsy state, probably associated with atelectasis 
and wasting, which he suspects is not uncommon. Henoch 
gives an accurate account of cases such as this : They occur 
in young children under a year with apncea, cyanosis, occa- 
sional evidence of bronchitis and broncho-pneumonia, con- 
traction of the fingers and toes, and occasionally convulsions. 
He mentions also that occasionally in the complexity of 
symptoms they simulate very closely cases of tubercular 
meningitis. While upon the subject of the mortality from 
whooping-cough, it may be added that in so far as the 
estimate drawn from the immediate cause of death, the rate 
falls no doubt far short of the reality — for, though it is dif- 
ficult to prove the fact, whooping-cough is a fertile source 
of caseous disease of the bronchial glands and tuberculosis, 
and of dilated bronchial tubes with all the chronic ills of 
lungs and heart which are associated therewith. 



PERTUSSIS. 3O9 

Modifications. — Pertussis is not a disease which shows 
much variety — it may be very mild so as hardly to be 
recognizable, or it may be very severe. Either stage may 
vary ; the febrile onset being excessive or prolonged and 
obscuring the paroxysmal, or the initial stage may be hardly 
noticeable and the whoop the first thing to attract attention. 
There may be much pneumonia or none at all ; and as 
regards other symptoms, there may be much or little 
haemoptysis — much or little vomiting — much or little 
wasting. The haemoptysis and vomiting are in proportion 
to the violence of the cough, and the wasting is in propor- 
tion to the vomiting. In very severe cases the whoop dis- 
appears altogether, and the cough is associated with an 
amount of laryngeal obstruction so as to resemble laryn- 
gismus. Such cases are liable to general convulsions, and 
are very dangerous. 

Complications. — It will only be necessary to mention 
epistaxis ; haemoptysis ;' ulceration of the fraenum linguae ; 
convulsions ; broncho-pneumonia ; pleurisy ; pericarditis, 
and laryngitis. Of these, convulsions and broncho-pneu- 
monia alone are of importance. Hemorrhage from the nose, 
mouth, or lungs, and a fortiori from the ear — which is men- 
tioned by writers as an occasional occurrence — is never so 
profuse as to cause any anxiety ; and ulceration of the 
fraenum linguae is hardly worth a note. It occurs occa- 
sionally. Dr. Goodhart noted its presence four times in 
twenty-two cases, and the editor has seen it in about the 
same proportion. It is an indication of a violent cough, 
and is probably due to the fretting of the fraenum against 
the lower incisor teeth. Epistaxis of some severity Dr. 
Goodhart noted as occurring thirteen times in 314 cases, 
though doubtless, in minor degree, it is present far more 
commonly than that. Haemoptysis is excessively common, 
and convulsions constitute an element of great gravity; 



310 DISEASES OF CHILDREN. 

they are mostly present in young children, or are associated 
with severe broncho-pneumonia. Of nine cases, five were 
children of a few months only — one nine weeks, one of 
twenty months, one of eighteen months, one of five months, 
one of seven months, one a " baby." The other three were 
cases of broncho-pneumonia with convulsions supervening, 
and probably causing death. In some children a profound 
stupor takes the place of convulsions, and if possible is of 
even graver significance. 

Broncho-pneumonia is met with in every variety as 
regards its degree and the position which the disease occu- 
pies in the lungs. As a rule it is characterized by being 
widespread. There may be patches of disease about the 
front of the lungs, along the anterior edges, or round the 
nipple more particularly. The root of the lung is a favorite 
spot for all the pneumonias of children, that of pertussis not 
excepted ; and not very uncommonly the disease may be 
excessive and occupy the greater part of one, or even both, 
bases. Moreover, it sometimes happens that a somewhat 
extensive pneumonia rapidly clears up. Dr. Goodhart has 
quite recently had a child aged two under his care in the 
hospital. There was extensive consolidation at both bases, 
indicated by loud tubular breathing and other signs, and 
the greater part had cleared in five days. On the other 
hand, broncho-pneumonia is also exceedingly likely to 
become chronic in pertussis, and in young children the 
middle lobe of the right lung appears, for some reason or 
other, to be particularly prone to slowness of repair. This 
lobe is very liable to pass into a solid condensed state, of 
leaden color, and on section to be studded over with cre- 
nated patches of caseous pneumonia, each with a dilated 
bronchial tube in the centre full of thick pus, or actually 
softening into cavities. Pleurisy is naturally not infrequently 
associated with whooping-cough, mostly by extension from 



PERTUSSIS. 311 

patches of pneumonic consolidation ; and pericarditis when it 
occurs probably originates in a similar manner by direct exten- 
sion. Laryngitis odours occasionally, but is rarely severe. 

Results and Sequela. — Emaciation may very properly be 
considered as a result of pertussis, for several reasons. In 
itself it is no unimportant condition that a child should be 
little more than a skin-covered skeleton. The viscera under 
such circumstances must run the risk of various forms of 
degeneration, and it might naturally be supposed that bad 
nutrition would dispose toward cheesy change in the glands 
and a secondary tuberculosis ; and that such is actually the 
case many have very little doubt. 

Atelectasis, or collapse of the lung, is another important 
consequence, important in itself, as being in young children 
extensive, and causing death; important in the further con- 
sequences it entails, of broncho-pneumonia, emphysema, 
and dilatation of the bronchial tubes, all which results come 
about very naturally as the consequences of collapse. The 
whooping-cough is associated with more or less bronchitis, 
and this with more or less secretion in the smaller bronchial 
tubes. The expiratory efforts drive the air from the pul- 
monary parenchyma, and, unable to return by reason of the 
plugs in the tubes, the lung becomes collapsed in various 
parts. The collapse leads to inflammatory processes in the 
lung, and the tubes of the part become dilated — very often 
a little pleurisy forms on the surface of these patches, and 
perhaps also some adhesion follows, which tends to increase 
the bronchial dilatation. 

Thus it is that after a bad attack of whooping-cough the 
child often remains delicate, with a small and laterally flat- 
tened chest, the lower ribs being expanded over the ab- 
dominal viscera, and thus causing the disproportion between 
the abdomen and thorax which is so common as a result of 
old atelectasis. 



312 DISEASES OF CHILDREN. 

The relation of cheesy bronchial glands and phthisis to 
pertussis is no doubt a question of much difficulty, for it is 
not only hard to obtain the direct proof when one disease 
succeeds another at some considerable interval of time, but 
it is also impossible in many cases to free this question 
from others, such as the effect of intercurrent or concurrent 
measles, of hereditary taint, constitutional predisposition, 
etc. Nevertheless, it is likely that both on the ground of 
probability and the ground of fact, pertussis is a frequent 
source of cheesy glands and tuberculosis. That such 
occurrences are probable, is only too evident when we re- 
member the bronchitis, the broncho-pneumonia, the swelling 
of the bronchial glands, that characterize so many cases of 
the disease, and on the ground of fact we are all unfortu- 
nately too familiar with so many cases where cheesy bron- 
chial glands, cheesy pneumonia, and disseminated tubercle 
in the lungs and viscera have succeeded pertussis, to have 
less than an almost positive conviction. It will be worth 
while to remember that when after pertussis the child remains 
wasted for a long time, and the cough still preserves its 
paroxysmal character even months after the attack, the case 
should be very carefully scrutinized from all points with 
reference to settling the question of the existence of gland- 
ular disease. 

The wasting may be due to mucous disease, a frequent 
accompaniment and not infrequent sequel of pertussis. The 
bulk of the mucus ejected at the end of the paroxysms of 
cough comes from the stomach, and the intestines, as shown 
by the stools, also secrete large quantities of tough stringy 
mucus. 

Etiology and Pathology. — It is a disease which is said to 
be more common in females than in males ; but Dr. Good- 
hart's figures make this doubtful — 136 out of 282 cases 
being males, or very nearly half. It is said also to be more 



PERTUSSIS. 3 I 3 

frequent in the spring months ; but neither does this appear 
very decidedly in this series, although the statement is 
probably correct : — 

Jan. Feb. Mar. April. May. June. 

Cases, 29 30 29 32 37 26 

Deaths, 2 3 1 3 o 7 

July. Aug. Sept. Oct. Nov. Dec. 

Cases, 22 10 6 14 ^^ 16 

Deaths, o o o 2 2 o 

The excess of mortality in the winter months is undoubted. 
It is a disease which occurs in epidemics and which is un- 
questionably contagious, while the contagion is capable of 
transmission from one child to another by articles of cloth- 
ing without any actual contact of the diseased with the 
healthy. It is also protective against any recurrence. Thus 
it has all the characteristics of a germ disease, although 
what may be the nature of the virus we, as yet, know nothing. 
It is usually supposed that the germs, which some have 
thought they have discovered in the shape of micrococci in 
the respired air and in the bronchial mucus, act locally upon 
the mucous membrane of the respiratory tract, and thus lead 
to the pulmonary phenomena which have been described. 
But this view fails to account satisfactorily for the neurotic 
element of the disease, and, on the whole, it is best to say 
that diphtheria is the disease with which it has most analo- 
gies. Diphtheria is unquestionably a blood disease, yet it 
tends to fasten itself upon the throat, and it is also followed 
by a nerve lesion which must be definitely localized if we 
are to judge from the uniform character of the paralytic 
symptoms. Whooping-cough behaves in much the same 
manner. In the first place, it would seem to be a blood 
disease, as evidenced by the onset and catarrhal stage of the 
fever ; and, in the next place, the virus localizes itself in part 
in the respiratory centre — and thus brings about a nerve 



3H DISEASES OF CHILDREN. 

discharge, which ends in the expiratory cough — and in part 
upon the pulmonary surface, leading to the swelling of the 
mucous membrane, the bronchitis, the pneumonia, and the 
swelling of the bronchial glands. Given these two sets of 
conditions, no doubt the one tends to intensify the other ; 
the over-sensitive bronchial surface will provoke nerve dis- 
charge, and the nerve discharge w r ill tend to increase the 
peripheral disturbance. The difficulty in the way of ac- 
knowledging the specific nature of pertussis — and that there 
is a difficulty is shown by the fact that some even yet call 
it a neurosis, and refuse to it any specific nature, while others 
feel there is something peculiar in its behavior which makes 
its presence incongruous in any group of diseases — seems 
to be in the impossibility of fixing what is the limit of the 
vitality of the contagion. In most of the specific fevers we 
have been able to fix some limit from the behavior of the 
disease ; but to pertussis there is none. It lasts mostly six 
weeks to two months, but the whoop may continue long 
after that. All that can be said of it in this respect is that 
it is most contagious in the early stages, but the virus ap- 
pears to want any definiteness of course. 

One cannot argue against the specific nature of the dis- 
ease from the absence of fever, and the tendency to recur- 
rence of a non-contagious cough; diphtheria is sometimes 
so mild as to have but little fever, and its nerve lesion is 
quite distinct from contagion. The cough is started by the 
disease, but soon tends to become a habit, and thus to 
return again and again, until it dies out in the oblivion 
engendered by more healthy and regulated discharges of 
neryous energy. It will be quite impossible to arrive at 
any conclusion upon the natural history of pertussis germs 
until we leave the whoop out of our calculations altogether, 
and pay more attention to the catarrhal stage. Dr. Sturges 



PERTUSSIS. 315 

argues for a somewhat similar end, though his line is not 
quite the same. He separates the two elements of the dis- 
ease into (1) epidemic catarrh, and (2) convulsive cough. 
The latter he considers to be a feature of cough in child- 
hood from all sorts of conditions, and having nothing in it 
of a contagious character save that of nervous mimicry. 
Whatever is specific, and whatever in the zymotic sense is 
infectious, Dr. Sturges considers to reside not in the cough 
but in the catarrh. Any child suffering from catarrh is 
liable to develop convulsive cough, and the rapid spread of 
convulsive cough is a sign and measure of epidemic catarrh. 
This hypothesis comes nearer the truth than any other yet 
put forward, Tor, while doing no violence to any known 
facts, it explains some of the anomalous traits of the disease. 
Dr. Goodhart is inclined to think, for instance, that it not 
only explains the relationship which exists between measles 
and whooping-cough, but that the relationship itself lends 
support to the view, if the whooping-cough usually follows 
the outbreak of measles. Nor need it be pointed out at 
any length how it falls in with the difficulty there is in 
fixing the limits of the life of the germ, and the duration, 
therefore, of its infective power, for there are few who 
doubt the contagious property of " a cold," if so vague a 
term may be used, and few who would dare to define its 
vitality in this respect. 

Dr. Sturges further supports his argument by appealing 
to an observation he has made at the Ormond Street Hos- 
pital, and the correctness of which the author has often 
had occasion to remark, that although cases of pertussis 
are not infrequently admitted into the general wards in 
the stage of catarrh and remain there often for several 
days — until, in fact, the case declares itself by the whoop — 
nevertheless, the disease is seldom or never conveyed to 



3 16 . DISEASES OF CHILDREN. 

other children. But this may mean no more than that 
the zymotic element is less active or diffusible than those 
of other infectious diseases. 

A child may go to school in six weeks from the com- 
mencement of the whoop, provided that the paroxysmal 
cough has ceased. Children who have come in the way 
of contagion must be kept apart from others for a fort- 
night. 

Morbid Anatomy. — The actual lesions found in whoop- 
ing-cough are not many. Of chief importance, at any rate 
as a cause of death, is broncho-pneumonia. This shows 
itself in children by more or less wedge-shaped patches of 
solid, perhaps tough, leaden-colored material, in which the 
vessels and tubes stand out prominently, and the latter are 
often dilated. If the diseased area is large, there will be 
seen, in addition, ill-defined areas of redder or paler color, 
dotting it over, perhaps, with a rather sandy or granular 
appearance. It is common to find the greater part of one 
or both lower lobes affected in this way, or the parts about 
the roots of the lungs, and spreading outward in the middle 
zone quite to the surface. The parts of the lungs corre- 
sponding to the mammary region are particularly liable to 
be affected, and thus to lead the unwary to conclude that 
he is dealing with a secondary phthisis. The bronchial 
tubes contain a thick glairy muco-pus, and the mucous 
membrane of the trachea and larynx are often injected or 
even minutely ecchymosed. The margins of the lungs are 
usually emphysematous. As regards the bronchial glands, 
there can be no doubt that they are liable to acute swell- 
ing; but the number of children dying of a perfectly un- 
complicated pertussis is not large, and in many cases the 
swelling that is found is the natural result of broncho- 
pneumonia. 

Various cerebral conditions have been described, such 



PERTUSSIS. 317 

as congestion, oedema, serous effusion, and the like ; but 
they are all of very doubtful significance ; ecchymosis, or, 
in some cases, larger extravasations of blood, such as to 
have deserved the name of meningeal apoplexy, can alone 
be said with certainty to have been due to this disease. 

In chronic cases other lesions are found ; the broncho- 
pneumonia undergoes degenerative changes which convert 
it either into solid cheesy masses or isolated nodules with 
softening centres. The bronchial tubes become more di- 
lated, and, in many cases, a disseminated tuberculosis of the 
lungs take place. The bronchial glands also are liable to 
lose their red, swollen, fleshy appearance, and to become 
converted into masses of firmer yellow cheesy substance 
like those in the lung. The explanation of these further 
changes is not hard to discover. The catarrhal pneumonia 
is well known to present under many circumstances a ten- 
dency to such changes, and the chronic disturbance of the 
respiratory tract, which we recognize as chronic bronchitis, 
is only too likely to perpetuate the initial hyperplasia of the 
bronchial glands and to lead to their caseation and to the 
development of acute tuberculosis of the lungs and viscera, 
or to an acute tubercular meningitis. 

Diagnosis. — There can be very little difficulty as regards 
the whooping stage ; but it may be as well to insist specifi- 
cally, although it, to a certain extent, follows from the re- 
marks already made upon the nature of the whoop, that the 
peculiar cough may return again and again upon trivial 
excitement. Further than this, it is allowed by all writers 
that chronic diseases of the bronchial glands sometimes 
produce a noisy paroxysmal cough very like pertussis. The 
distinction will be in the absence of any definite stage ; the 
absence of any evidence of infection — such cases occurring 
sporadically and not in epidemics ; the absence of whoop ; 
the evidence of associated lung disease ; possibly symptoms 
27 



3 18 DISEASES OF CHILDREN. 

of spasmodic asthma; and a history of wasting long before 
the occurrence of the cough. 

In enlarged bronchial glands there is dullness over the 
first bone of the sternum, stridor on inspiration and weakened 
respiratory sound over the lung provided a bronchus be 
pressed upon, and if the return of blood in a large vein is 
interfered with, besides lividity of the part and turgescence 
of the vein, there will be a hum heard through the stetho- 
scope placed over the seat of pressure. Before the swelling 
has become so large as to produce the symptoms just men- 
tioned, Eustace Smith's method of examination gives most 
assistance in making the diagnosis. He writes : " If the 
child be made to bend back the head, so that his face be- 
comes almost horizontal, and the eyes look straight upward 
at the ceiling above him, a venous hum, varying in intensity 
according to the size and position of the diseased glands, is 
heard with the stethoscope placed upon the upper bone of 
the sternum. As the chin is now slowly depressed, the hum 
becomes less loudly audible and ceases shortly before the 
head reaches its ordinary position." 

In the catarrhal stage, however, there may be consider- 
able difficulty in making a diagnosis. Indeed, we often 
can only have our suspicions and act accordingly, watching 
in individual cases for a confirmation in the onset of the 
paroxysmal cough. Here, as in so many other conditions, 
to be forewarned and on the look-out is the true prepara- 
tion against mistakes, not a definite memoria technica of 
phenomena, any one of which, or all, may fail us when 
doubts arise and we come to test them. 

In the presence of an epidemic, if the cough be paroxys- 
mal and worse at night, if the eyelids are puffy and marbled 
with injected vessels, and the conjunctiva suffused, the onset 
of whooping-cough may be strongly suspected. 

Prognosis. — In very young children (under a year old) 



PERTUSSIS. 319 

the disease is always a cause of anxiety; but in uncompli- 
cated whooping-cough at four or five years of age the mor- 
tality is not large. The gravity of the case will depend upon 
the complications that may arise. If there should be much 
broncho-pneumonia, naturally the danger will be great ; so 
also if convulsions are severe. Then, again, if the child is 
rachitic and its chest walls retracted, the occurrence of 
whooping-cough will tend to increase the already existing 
collapse and bronchitis and to set up pneumonia, and the 
risk increases in proportion. 

The frequency with which complications occur must vary 
no doubt in the practice of individuals; but it may be as 
well to state that Meigs and Pepper give, as the result of 
their practice, 65 cases associated with complications out of 
208, or nearly one-third. Of 320 cases of Dr. Goodhart's 
57 had broncho-pneumonia or bad bronchitis; 16 others, 
various other complications. Probably, therefore, from a 
fourth to a third of the cases may be expected to be com- 
plicated in some way, varying somewhat with the epidemic- 
influence and the time of year at which the cough occurs. 
Atmospheric changes have a most important bearing upon 
pertussis. It has been repeatedly noticed in the whooping- 
cough ward at the Evelina Hospital that the children are 
worse, even when otherwise doing well, when the wind turns 
cold or suddenly changes ; and it is notorious that the dis- 
ease runs a much less determined and persistent course in 
summer than in the colder seasons of the year, in other 
words, at times when epidemic catarrh is not prevalent. 

Lastly, beware of too hastily assuming the existence of 
phthisis where the broncho-pneumonia runs a chronic 
course ; for it is noteworthy that not a few cases with pro- 
nounced signs of chronic consolidation of various parts of the 
lungs and extreme emaciation ultimately — and sometimes 
rapidly — mend and become completely restored to health. 



320 DISEASES OF CHILDREN. 

Treatment. — This is a very important part of the subject 
if it be true, as is said, that this is the most fatal of all dis- 
eases of children under one year. Some people think and 
teach that whooping-cough will run its course and gradu- 
ally wear itself out, and that no drugs influence it materially. 
Some deny to it any specific virus, and consider it merely a 
nervous trick associated with catarrh, and, just as some 
tricks are easily caught in childhood, so, they say, is the 
whoop of whooping-cough. It is no doubt a disease in 
which, until trial has been made, it is difficult to say what 
drug will act best in any particular case. But that there are 
drugs which are of decided use cannot be doubted, and there 
are moreover other points in the treatment which it will be 
well to make oneself acquainted with. In the first place let 
it be again repeated that whooping-cough is generally a 
disease of two stages ; there is the primary catarrhal stage 
— in which the child is feverish and ill ; and there is the 
after or whooping stage — in which the child may not be ill 
at all, though this of course will necessarily depend upon 
the severity of the disease. 

Hitherto, attention has mostly been directed to the arrest 
of the whoop. But just as in common " cold " remedies 
seem to do little when the coryza is well set, so here, if we 
are ever to do anything to cut short the disease, it must be 
by attacking it in the early stage. There is no reason why 
we may not some day find a specific for the catarrhal stage 
of pertussis, as quinine is for ague, mercury for syphilis, or 
arsenic for some forms of skin disease. With this end in 
view, various forms of antiseptics have been tried, and some 
not without benefit. Carbolic acid given internally is per- 
haps sometimes of use ; a minim or more, according to age, 
of the glycerine of carbolic acid may be given at intervals 
of three or four hours. From its action as a vapor Dr. 
Goodhart is doubtful; he for some time impregnated the 



PERTUSSIS. 321 

air of the whooping-cough ward at the Evelina Hospital 
strongly with it; little effect upon the disease could be per- 
ceived. The more economical way of carrying out this 
treatment is to obtain the vapor from Calvert's powder by 
means of the small tin lamp and dish sold for the purpose 
by the manufacturers. Cresoline gives a similar sort of 
vapor — Dr. Goodhart has tried it without definite results ; 
he thinks more highly of trochisques Vichot, first recom- 
mended to him by Mr. Benjamin Duke. They are pastilles 
of some crcasote compound, and, vaporized within a tent 
three or four times a day, they compel a prolonged and 
more concentrated inhalation, and appear to be sometimes 
useful. The editor has seen cresoline act well, but the best 
results are said to be obtained from sulphur. The plan is 
to have the patient put into clean clothing and removed 
from the chamber to be used as a sick-room, in the morn- 
ing. All the clothes and the toys to be subsequently used 
are brought into this room, and then sulphur is burnt upon 
live coals in the centre of the apartment. In the evening 
the child is brought back. About one ounce of sulphur to 
every cubic metre of room-space, is the proper proportion 
for the fumigation. The belief is that the sulphurous acid 
generated destroys all pathogenic spores lurking in the air, 
bedding, clothing, etc. 

For a year past all of Dr. Goodhart's cases have been 
treated by a frequent resorcin swab ; a 1 per cent, solution 
in water has been painted on the throat every three hours. 
This drug has been strongly advocated by Moncorvo, on 
the hypothesis that the germs of the disease reside in the 
epithelial cells of the mucous membrane of the larynx and 
pharynx. Good results have been obtained from the treat- 
ment by Dr. W. H. Barlow of Manchester. Upon the 
whole, the cases have done well, but in no case could it be 
said to have as yet reached perfection, for the average dura- 



322 DISEASES OF CHILDREN. 

tion of the cases has been hardly short of that of former 
years. Monti's treatment by nasal insufflation has proved 
very efficient in the editor's hands — two to three grains of 
powdered benzoin or boric acid are blown up the nose by 
some efficient insufflator every three hours or oftener 
during the day, and once or twice at night. Goodhart 
thinks this plan also sometimes of decided value ; some 
time ago he tried benzol, with apparently good results. 
For some months all, or nearly all, uncomplicated cases of 
pertussis that came to the out-patient room were given five 
to ten drops in syrup and water, and many had previously 
taken other remedies without avail. The cough in many 
became less frequent and less violent. The one objection 
is that the smell and taste of paraffin cannot be disguised, 
and that it occasionally causes sickness. Antipyrine is 
another new and useful remedy. When employed in the 
initial stage it brought the attacks to a close, with mitigated 
symptoms, in from three to five weeks. When the treat- 
ment was not begun until later in the attack, the paroxysms 
were at once influenced for the better, the first indication 
of an improvement being a freer expectoration. This was 
quickly followed by general improvement and increased 
ability to retain food. In no instance was collapse pro- 
duced. Complications occurred in only five of seventy 
cases ; in two, pneumonia, and in three tuberculosis. 

What the action of antipyrine may be cannot at present 
be positively affirmed. Sonnenberger seems to incline to 
the theory held by Binz, that the effect of the members of 
the chinolin group within the organism is anti-parasitic, as 
it is outside, and that we thus have an actual specific 
against whooping-cough. To this must be added a very 
remarkable sedative influence in certain irritable states of 
the nervous system. 

Antipyrine may be given to children in doses of from 



PERTUSSIS. 323 

one-quarter of a grain to three or five grains, according to 
the age. It is best administered in the form of powder, in 
sweetened water. It is not disagreeable to take, and has 
no bad effect upon the digestion. It may be continued for 
several weeks without ill results. 

Such are some of the remedies that have received a 
more or less general certificate of usefulness in this par- 
ticular domain. One often hears or sees this one or that 
lauded more enthusiastically than is proper because it is 
found that remedies that have proved useful in private 
practice or in the out-patient room, when tested in a ward 
set apart for the treatment of the disease in hospital, and 
by the more rigid appeal to facts thus allowed, have given 
results of much more equivocal nature. At the same time 
it is only proper to remark that too much must not be 
made of this. It is true that pertussis is notoriously un- 
certain in its behavior, and thus may seem to do well under 
the influence of a drug that has in reality done little or 
nothing. But, on the other hand, those who are most cer- 
tain of the value of drugs are those who see the disease in 
its earliest stages, and therefore at the very time when 
remedies of a particular kind are the most likely to act 
with effect. The average run of cases in a whooping-cough 
ward are bad ones, with much broncho-pneumonia, and in 
many respects deterrent to the free action of any drug. 

In addition to remedies of the germicide class there are 
others, old-fashioned perhaps yet still of undoubted value. 
There are few remedies of more value than simple ex- 
pectorants. Dr. Goodhart gives the mist, oxymellis co. of the 
Guy's Pharmacopoeia, which consists of vin. ipecac, tr. opii 
camph., nitrate of potassium, and oxymel. Sometimes, if 
the child is four or five years old, tr. opii camph. alone is 
sufficient, the benzoic acid and opium making it a good 
sedative expectorant. Often a little dilute nitric acid proves 



324 DISEASES OF CHILDREN. 

useful. Some have suggested this as a specific for whoop- 
ing-cough ; and though it is impossible to indorse this 
view, many children seem to be relieved by its use, and 
with syrup, and perhaps a little tolu, it does not make a 
bad mixture for a child to take. Chloride of ammonium 
and citrate of potassium are also useful. For the whoop- 
ing stage also many remedies have been suggested. There 
can be no doubt that all drugs fail to cut the disease short 
in most cases, but some are of considerable value in con- 
trolling it. Belladonna must be placed first. It cannot be 
doubted that it is often very effective ; but chiefly so when it 
is given in large doses. Trousseau advises the use of the 
extract of belladonna given in the morning as a single dose, 
beginning with one-third of a grain and gradually increasing 
it. Dr. Goodhart prefers the tincture of the liq. atropiae.* 
These are more manipulable, while the dose of either can 
be readily increased, and it is essential to the treatment 
that considerable doses should be administered if the 
remedy is to do good. Many advise that the drug should 
be pushed until it produces some known physiological 
effect. The necessity of this is questionable. Children 
are very tolerant of belladonna, and the cough is generally 
controlled some time short of any poisonous effects. At 
any rate, our own experience undoubtedly corroborates 
that of most other observers as to the good effects of the 
drug, although we have seen but few instances, and those 
of children in hospital, where any physiological effect (dila- 
tation of the pupil) has been produced. As regards the 

* Liquor atropiae, Br. P., contains : — 

Atropia, 4 grains. 

Rectified spirit, I fluid drachm. 

Distilled water, 7 fluid drachms. 

Dissolve the atropia in the spirit, and add this gradually to the water, 
shaking them together. 



PERTUSSIS. 325 

actual dose, three to six drops of the tincture may be given 
to a child three years old to commence with, and the quan- 
tity increased up to twenty drops or more if necessary, and 
this every three or four hours. Even in very young chil- 
dren large doses may be given with advantage ; Dr. Good- 
hart has given ten drops three times daily to a child of five 
months old, and no dilatation of the pupils resulted. This 
child began at fourteen weeks with four minims, the dose 
was then increased to six, afterward to eight, and then to 
ten drops ; and infants of five and six weeks old will take 
four or five minims easily, and with relief to the violence of 
the cough.* 

But as regards the tolerance of the drug which children 
exhibit, it must be remembered that although it is un- 
doubted, it is always wise to feel one's way, and to watch 
the effects carefully. It is best to begin with some dose 
proportionate to the age, one or two drops in babies, and 
two, three, four, or even five, for older children, and watch 
its effect. Should it control the cough — well, what need to 
increase the strength ? If not, let the dose be increased 
drop by drop till it does so or fails, when something else 
must be tried. Some prefer to give the drug in small doses 
at more frequent intervals, and there is much to be said in 
favor of this plan on the score of scientific therapeutics. 
But, except in hospitals with trained nurses, it is difficult so 
to work it as to run no risk, unless the child's attendants 
be exceptionally furnished with medical intelligence. But, 
however we give it, it will undoubtedly relieve many cases, 
and appear to stop some. 

Belladonna by inhalation has been employed with very 
satisfactory results, reducing the frequency of the paroxysms 

* The difference in the strengths of the British and American preparations 
of belladonna must be remembered. The latter are about twice as strong. 
28 



326 DISEASES OF CHILDREN. 

of coughing and overcoming the whoop after from four to 
eight inhalations. Enough should be inhaled to produce 
some dilatation of the pupils. 

There are many other drugs which are useful. Quinine 
certainly does some cases good, but it requires, like bella- 
donna, to be given in somewhat large doses. It may be 
administered either by the mouth or rectum. Some time 
ago the author tried benzol in this stage, and certainly with 
good results. The editor employs antipyrine and nasal 
insufflation in this stage with good results. 

Alkalies are also very useful. The carbonate of potas- 
sium, in doses of a few grains every few hours, is strongly 
recommended by Meigs and Pepper as useful in their hands 
and those of others ; and the combination of bicarbonate 
of sodium and belladonna, a mixture that has long been 
in vogue at the Evelina Hospital, is a very valuable 
remedy. 

Alum is a medicine which may perhaps be mentioned 
next, because, though it is in some cases singularly useful, 
its action is probably the opposite of the alkaline carbonates. 
They possibly aid by facilitating expectoration — the use of 
alum, on the contrary, is said to be indicated when there is 
already an excessive secretion from the bronchial tubes. 
Dr. Goodhart, having tried it with this special object, feels 
free to confess a considerable doubt as to ever having had 
the drug control the disease, though he has no doubt as to 
its occasional value. The editor uses it frequently and has 
found the following combination with belladonna very 
useful : — 

R . Pulv. aluminis, gr. xxiv 

Ext. belladonnse, gr. ^ 

Syrupi zingiberis, 

Aquae, aa f^j ss - M. 

Sig. — One teaspoonful every two hours, for a child of one year. 



PERTUSSIS. 327 

Then, again, the bromide of ammonium or of potassium, 
and chloral are highly useful in some cases. The succus 
hyoscyami, and other nerve sedatives and antispasmodics, 
are useful in their turn, and, indeed, there is much about 
the treatment of pertussis which brings out clearly the neu- 
rotic element, for, like epilepsy, it would seem that there are 
many drugs which avail for a time, but in the long run, and 
when surveyed rigidly, one seems to have as much or as 
little influence as another. 

There are other important points in treatment which are 
not less worthy of notice. Whooping-cough is a disease 
which, in most cases, is attended with frequent vomiting. 
The paroxysms of coughing will come on twelve, fifteen, 
twenty times in the course of the day, and each time very 
likely will end with vomiting. It is therefore easy to under- 
stand that nutrition is in some cases much interfered with, 
and the child becomes much emaciated — is, in fact, starved. 
In these cases the most watchful care is required, and the 
routine must be entirely subservient to this exigency of 
vomiting; the food should be entirely fluid and highly 
nutritious; in some cases it may with advantage be artifi- 
cially digested, and it must be given very often, a little at a 
time. For this purpose, beef-juice is very useful in bad 
cases. Moreover, food should always be administered di- 
rectly after an attack, so that as long a time as possible may 
be obtained for absorption before the contents of the stom- 
ach are again rejected, By this means a good deal may be 
done to combat excessive wasting, and in averting this we 
no doubt do the best that can be done to ward off those 
degenerative changes of which mention has already been 
made. 

Of other remedies, let me first mention an occasional 
emetic as very useful in the earlier days of the whooping 
period. It clears the bronchial tubes of their contained 



328 DISEASES OF CHILDREN. 

mucus, allows the lungs free play, and in this way by acting 
at the periphery does what can be done to quiet the central 
instability. 

In the later stages, friction to the spine is an old and use- 
ful remedy, and in the chronic whooping stage, few things 
act so satisfactorily as a change of air. 

It is necessary to insist that the remedies which are used 
for the second stage are not suitable to the first, specifics 
being, of course, excepted. The remedies now in vogue 
for the second stage are in no sense specifics ; they control 
the violence of the paroxysm, but have no destructive action 
upon the supposed germ which causes them. But if the 
disease be due to a germ, and the behavior of the disease 
is certainly in favor of this view, then it may be hoped that 
a specific will one day be found, and obviously any drug 
exhibited with such an object must be applicable at any time 
during the life of the germ. 

The treatment of broncho-pneumonia is given under 
that heading in the chapter on diseases of the respiratory 
system. 

10. Typhoid Fever. — No period of life is exempt from 
enteric fever, and cases sometimes occur in infants of but a 
few months old. Of forty-six cases from the author's notes, 
two were under a year old (both being fatal, and the diag- 
nosis verified by an inspection), one under two, two of three 
and under, two of four, six of five, five of six, six of seven, 
six of eight, six of nine, seven of ten, and three of eleven 
years, so that thirty-nine of the forty-six were over four 
years of age. 

Symptoms. — As in adults so in children — fever, rose spots, 
diarrhoea, enlargement of the spleen, and bronchitis are the 
prominent symptoms. Children are not exempt from the 
tendency seen in adult life to a repetition or relapse of all 
the symptoms, when the primary fever has completely, or 



TYPHOID FEVER. 329 

all but, run its course. The disease is generally milder in 
children than in young adults ; and its more markedly 
remittent type is notorious. The fever is, generally speak- 
ing, of insidious onset. Headache and loss of appetite are 
first noticed, accompanied, perhaps, by occasional vomiting. 
Jacobi speaks of chills and somewhat persistent vomiting. 
It is characterized often by very few symptoms during the 
day — except fretfulness — though symptoms of fever, with 
quick pulse and dry skin, are not wanting to careful obser- 
vation. Toward evening the face becomes flushed, or a 
red burning spot surmounts one cheek, the lips become red, 
and the tongue dry ; the child's sleep is restless and dis- 
turbed by delirium ; towards morning the fever subsides, 
and hopes are entertained of speedy recovery. Day after 
day the same history repeats itself, and now the abdomen 
is tumid, the spleen is large ; there is diarrhoea, and perhaps 
rose spots appear; there is considerable cough, and the 
child rapidly becomes emaciated. Sometimes during the 
afternoon profuse sweating may set in, though without relief 
to the symptoms. From these remissions the term " in- 
fantile remittent " takes its rise ; they are sometimes very 
marked and appear to continue throughout the fever, gradu- 
ally lessening in severity as it runs its course. 

This complete picture often fails. The duration of the 
fever is more variable, diarrhoea may be absent, and the 
roseola also. Even the splenic enlargement may be want- 
ing, so that the disease is perhaps only established by the 
temperature chart, together with the existence of an asso- 
ciated bronchitis. A large number of cases occur with no 
distinctive feature of any kind. It is noticed that a child is 
ill, and its temperature is found to be high — ioi° to 103 ; 
a more rigorous observation is then instituted, and it is kept 
in bed. Then it is found that there is a continuous fever 
with evening exacerbations for some days, accompanied by 



330 DISEASES OF CHILDREN. 

tumidity of the abdomen, and a coated or beefy condition 
of the tongue. At the end of ten or twelve days there are 
more marked remissions, or else by some sudden fall the 
fever ends, and convalescence is established. 

In default of any definite symptoms, there is a disposition 
to consider cases such as these as instances of mild ty- 
phoid. Some German authorities, however — Lebert for 
instance — adopt the term infective gastritis for febrile attacks 
of this kind ; supposing, in unison with doctrines now in 
vogue, that the products of gastric catarrh are capable of 
infecting the system generally, and thus of keeping up a 
continued fever. The " gastric fever" of English authors 
might usefully be made to convey a like suggestion ; but 
that in common parlance it has come to be synonymous 
with typhoid fever. There is no intention of asserting dog- 
matically that an infective gastritis distinct from typhoid 
fever has an existence, but the possibility of such a thing 
is alluded to for the purpose of impressing upon the stu- 
dent that in dealing with continued fever of indefinite type 
in childhood, he is to bear in mind that other causes than 
the assumed one have a claim to consideration, and that 
careful observation and record of all such indefinite types 
are necessary, in the hope that at some future time some 
order may be introduced into the at present chaotic domain 
of " simple continued fever." 

In adults the pyrexia of typhoid is characterized by a 
gradual rise in three or four days to the acme of the fever. 
Next, by a period of continuous fever (103 to 104 ), the 
morning temperature being a degree or so lower than that 
of the evening ; and at the end of the second, or early in 
the third week, the period of remission sets in, the morning 
temperature falling to near the normal line, the evening rise 
still continuing for some days. In children the same three 
stages may be noticed, but they are seldom so continuous 



TYPHOID FEVER. 33 I 

or so well marked. The remittent nature of the affection is 
the most prominent feature of infantile typhoid, and may 
characterize more or less the whole course of the disease. 
Further, the remissions need present no regularity from day 
to day in time of their occurrence. If the temperature be 
only noted morning and evening, no doubt in the latter it is 
often high, in the former low ; but taken every two or three 
hours, the chart will be remarkable for its irregularity, 
sometimes running up and down several times in the course 
of twenty-four hours ; and the highest point reached may 
be at any hour, often about 6 p.m., but sometimes 9 p.m., 
6 a.m., 12, midnight, or 3 a.m. 

The accompanying chart (Fig. 7), taken from a girl ten 
years of age, a patient in the Children's Hospital of Phila- 
delphia, will show the ordinary morning and evening range 
of temperature in typhoid fever. The child had been ill 
two weeks before coming into the hospital, and therefore 
a portion of the chart represents the temperature at the 
end of the initial attack of fever, the remainder shows the 
temperature during the relapse. 

All authors appear to have noticed a tendency to the oc- 
currence of two distinct exacerbations about 4 and 9 p.m., 
with intervening remission and occasional profuse sweating. 
The oscillations in these cases are extreme, and if long con- 
tinued are indicative probably of severity of ulceration. 
The difference between the lowest and highest temperature 
for the twenty-four hours should not exceed two or, at 
most, three degrees. 

In severe cases there may be a good deal of noisy de- 
lirium occasionally showing itself by a frequent harsh cry, 
not unlike that of tubercular meningitis, and very perplex- 
ing for diagnosis ; in cases of moderate severity the child 
lies stupefied and apathetic, with more or less mild delirium 
at night. Deafness is not uncommon. 



332 



DISEASES OF CHILDREN. 





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TYPHOID FEVER. 333 

Rose spots are present in many cases that are seen at the 
proper time, though they are by no means so uniformly 
present as in adults. To determine their presence it is 
necessary to examine the entire trunk day by day. But 
many children among the poorer classes are only brought 
to the hospital at the last stage of the disease for continued 
ailing or emaciation, which is thought by the parents to 
indicate consumption. In many such the rose spots are 
absent. They are absent throughout in perhaps a fourth 
of all the cases. In a considerable proportion they are but 
few in number, and may easily be overlooked. As in adults, 
they appear in crops from the eighth to the twelfth day 
onward. Sudamina are often seen late in the second or 
third week. 

Bronchitis may be a prominent symptom, and not infre- 
quently is associated with slight haemoptysis ; sometimes it 
is very severe, and it may prove fatal. Dr. Goodhart has 
seen it so severe as to mask the nature of the disease alto- 
gether, the case assuming the aspect of acute bronchitis. 

Splenic enlargement is present in many cases, and should 
always be looked for as an aid to diagnosis. Henoch states 
that he found it palpable in thirty out of seventy-five cases ; 
in others it could be distinguished only by percussion. It 
appears about the same time as the spots and is present 
sometimes in the primary fever, sometimes in the relapse. 
It is in all probability related to the intensity of the fever ; 
but too little is known about the symptom to speak with 
certainty. 

The tongue is often characteristic. It may be coated 
with a white creamy fur on the dorsum, with red edge and 
tip, or it may be of a beefy red all over, with prominent 
papillae or unnaturally smooth. 

The Duration is much more variable in children than in 
adults ; many cases last only ten or twelve days ; seventeen 



334 DISEASES OF CHILDREN. 

to nineteen days is not by any means an uncommon dura- 
tion. Then, again, many cases give a preliminary history 
of three or four weeks of malaise before the onset of any 
definite symptoms. It is probable, however, that could 
these be more carefully watched, they would resolve into 
cases in which a mild primary fever, unrecognized, had led 
on to a relapse. For instance, a girl, aged seven and a 
half, had been ill three weeks, had been much worse for 
seven days, and had suffered from diarrhoea for three days. 
She was admitted to the Evelina Hospital with a steady 
fever of 104 , diarrhoea, rose spots, and enlargement of the 
spleen, and the complaint ran a course of fifteen days. 
The total period was thus divisible into two or fourteen 
days each. Again, a boy, aged five, said to have been ill 
three weeks, but worse with diarrhoea three days, was ad- 
mitted with a temperature of 104 , and the complaint ran 
a course of nineteen days; a total, again, well divisible into 
two attacks of between two and three weeks each. Many 
such cases could be given. 

Morbid Anatomy. — The ulceration of Peyer's patches and 
of the solitary glands is less frequent, less extensive, and 
less characteristic than in adults, and the younger the child 
the more is this true. In not a few cases no ulceration of 
any kind has been present ; in others, one or two small 
ulcers in parts of the agminated glands ; in others, slight 
raised fleshy swellings of the entire patch or of parts of it. 
As in adults, the large intestine may be affected — nay, may 
even be the chief seat of ulceration ; and the author has 
once seen death from the after-result of hemorrhage from 
typhoid ulceration of the colon. Perhaps it is in conse- 
quence of the mildness of the ulceration that the fever is so 
variable that tympanitis and hemorrhage from the bowels 
are uncommon, and that death by perforation is one of the 
rarest modes of termination. Otitis may be present, and, 



TYPHOID FEVER. 335 

in rare cases, parotitis, which may prove fatal. Dr. Good- 
hart has only once seen death from acute peritonitis. It 
was associated with jaundice, ascites, and pleuritic effusion 
in a child of four and a half years. For the most part, the 
morbid anatomy of typhoid fever in children differs from 
that of adults by wanting all the more characteristic fea- 
tures. Slight ulceration of the solitary glands and of 
Peyer's patches, or swelling only, combined with a swollen 
spleen, and more or less sodden solidification of the bases 
of the lungs, complete the picture in most cases. 

The following case may be given as an illustration of 
these points. It is an exceptional one for two reasons : the 
early age of the child and the fatal result : — 

A male child, four years old, attended as an out-patient 
at the Evelina Hospital with diarrhoea, a tense abdomen, 
and some rose spots on its buttocks. It was only seen 
once. It died in convulsions. Dr. Goodhart made an in- 
spection three days after death. The spleen was large and 
rather soft. The mesenteric glands were large and ecchy- 
mosed. Throughout the small intestines Peyer's patches 
were injected and swollen, so as to be slightly raised above 
the surrounding level in a flat plaque. The upper patches 
were mostly ulcerated ; one lower down had a circum- 
ferential line of ulceration as from a slough just commenc- 
ing to separate, and others of them had small ulcerated 
pits in them. The ileo-caecal valve was ulcerated. 

There can be little doubt that this was a case of typhoid 
fever. There was the large, soft spleen, the swollen and 
ecchymosed glands, and the swollen and ulcerating Peyer's 
patches ; but the swelling of these was very slight as com- 
pared with that usually seen in adults. 

Diagnosis. — It is a matter of frequent occurrence that a 
pale, wasted child is brought to a hospital out-patient room 
with a history of four or five weeks' illness, with diarrhoea 



33^ DISEASES OF CHILDREN. 

and cough, the expectoration being slightly streaked with 
blood. These are signs from which the student not unnatu- 
rally concludes that the disease is of phthisical nature. More- 
over, this opinion may be apparently confirmed when the 
chest is examined and he finds bronchial rales present ; or 
some roughened respiration at the apices which he con- 
siders to be bronchial, and therefore to indicate consolida- 
tion. A further examination, however, shows that there is 
no dullness on percussion, and but slight, if any, difference 
between the abnormal sounds on the two sides, and, per- 
haps, the tongue is red and glazed, and the abdomen full. 
After a day or two in bed the case turns out to be typhoid 
fever in the second or third week. So often does this pic- 
ture present itself in practice, that it is of importance to 
insist that when in children prima facie phthisis is indi- 
cated, the student should have typhoid fever as an asso- 
ciated idea and proceed to decide between the two. Typhoid 
fever is one of the wasting diseases of childhood. 

Sometimes it is quite impossible to decide between acute 
tuberculosis and typhoid fever ; the insidious onset is the 
same for both, and the temperature chart of both is one 
of oscillations, owing to the evening exacerbation of the 
fever. Vomiting is sometimes a feature of early typhoid 
fever, and a slow pulse not by any means infrequent. On 
the other hand, diarrhcea may be met with in acute tuber- 
culosis, and a tuberculous spleen may often be felt below 
the ribs. Thus it may happen that a positive opinion can 
only be arrived at after careful observation, at more than 
one visit, of all the circumstances of the case, and that in 
some cases — perhaps not very common, but yet sufficiently 
frequent to necessitate insistance on the fact — the two dis- 
eases cannot be distinguished. 

Meningitis is sometimes extremely difficult to distinguish 
from typhoid fever. The following cases illustrate this : — 



TYPHOID FEVER. 337 

A boy, aged twelve, came home from school ailing, after 
the mumps. A boy at the school had had typhoid fever 
there some months previously, but he was thought to have 
taken it from elsewhere, the drainage and sanitary condi- 
tions being perfect. The lad was pale and thin, with a rather 
beefy tongue, a full and tense abdomen, and a large spleen ; 
his evacuations loose, but not frequent ; no spots ; tempera- 
ture, ioi°. For twenty-four days he thus continued, per- 
fectly clear in his intellect, but with slight intolerance of 
light, a frequent short cough, a high but oscillating tem- 
perature, and gradually increasing muscular tremor. He 
also had rather frequent priapism, the import of which did 
not strike me till afterwards. Gradually a dry pleuritic rub 
developed, and some evidence of partial consolidation, in 
diminished resonance and blowing respiration in the scapu- 
lar region. Next there came pain on movement, delirium 
at night, and then almost suddenly he passed into a coma- 
tose condition, with rigidity of his extremities and more 
priapism, and he died after an illness of thirty days. For 
more than three-fourths of that time it was quite impossible 
to decide between typhoid fever and general tuberculosis ; 
but his mode of death, combined with various slight symp- 
toms which could be read more distinctly after — viz., the 
intolerance of light, the priapism, the muscular tremors, 
and the pains in his extremities on movement — made the 
diagnosis without doubt to be cerebro-spinal meningitis. 

Another case, a boy aged five, was admitted with a his- 
tory of three weeks' illness, chiefly of frontal headache, 
vomiting, and latterly diarrhoea. His temperature was very 
high (i03°-i04°), the condition of one lung was question- 
able, and he had much delirium. For seventeen days he 
continued in the same condition, without any definite signs 
of typhoid fever, and with many of severe cerebral disturb- 
ance and fever. He had, however, an occasional typhoid- 



33$ DISEASES OF CHILDREN. 

looking stool, and the temperature ran high for tubercular 
meningitis ; therefore, on the whole, the diagnosis of fever 
was favored, and so it proved to be. From the seventeenth 
to the twenty-fourth day the temperature fell, and the child 
got well. 

The third case is that of a girl, aged twelve. She had 
been subject to sick headaches for a long time, but worse 
since a blow on the head a year before. She had also wasted. 
For five days the headache (frontal) had been very bad, with 
frequent vomiting and constipation. She was quite clear in 
her mind, with temp. ioo°, pulse 72, exceedingly irregular, 
but with no intolerance ; the fundus of the eye being nor- 
mal. The disease ran on without declaring itself till pain 
in the neck developed, then squint, then coma. 

Ulcerative endocarditis will sometimes closely simulate 
typhoid fever, and is all the more difficult to distinguish, in 
that the physical signs of valvular lesion are apt to become 
masked by the formation of fungating vegetations about the 
diseased apertures. Any previous history of rheumatism, 
any evidence of valvular disease, and particularly any evi- 
dence that infective maladies of any kind are prevalent, 
should suggest a careful consideration of this possibility be- 
fore coming to any definite opinion. 

Ostitic pyaemia may simulate typhoid fever, and a case of 
this kind has recently been in the Evelina Hospital. A 
child of about eight was admitted, with diarrhoea, much 
abdominal distention, and the general aspect of severe 
typhoid. The result showed a very acute pyaemia, with 
abscesses in parts of the lung. 

Of the incubation and other points concerning typhoid 
fever in general, it is hardly within the scope of the present 
work to treat ; but it may be remarked that, as regards the 
incubation — which is said to vary from two days to three 
weeks, and to be most commonly about two weeks — children 



TYPHOID FEVER. 339 

afford virgin soil, undergo changes of body-heat readily, and 
therefore may be expected to mature a poison rapidly ; an 
important consideration when tracing the source of infection 
or attempting to fix the probable duration of the attack. 
Further, it would seem that children are peculiarly sensitive 
to drain emanations, while water and milk, which con- 
stitute so large a share of their diet, have been shown to be 
the more common source of the introduction of the poison. 

Treatment. — In the majority of cases the treatment is 
simple. The child must be kept in bed, its temperature 
carefully watched, and the diet regulated. The food must 
be fluid — such as milk and beef-tea. Should the stomach 
be inclined to reject these, even lighter materials must be 
given — milk and lime-water, or milk and water, whey and 
artificially digested milk. 

In convalescence pultaceous foods, as custards and blanc 
mange, may be cautiously administered, and a full diet very 
gradually returned to. 

As regards drugs, a little dilute nitric or muriatic acid, 
with syrup, is agreeable and refreshing, and some attach 
importance to its therapeutic value. Quinine is another 
remedy much in vogue with some. In cases of moderate 
duration, no stimulants are necessary ; but when the fever 
extends to, or beyond, the third week, and the symptoms 
have been severe, two, three, or four ounces of wine, or one 
or two of brandy, in the twenty-four hours, are often needed 
after the second week. 

Constipation is not uncommon, and, if associated with 
any distention of the abdomen, is to be treated by simple 
enemata, or a small dose of castor-oil. The evacuations 
should in all cases be treated with some disinfectant, and 
all soiled linen is to be removed at once and treated in like 
manner. 

As regards the more severe cases, the noisy delirium may 



340 DISEASES OF CHILDREN. 

perhaps indicate the need of stimulants ; but the relief 
afforded is not so decided as in adults, and, as a rule, need 
not be employed, provided the child is taking its nourish- 
ment well. Small doses of Dover's powder or bromide of 
potassium are sometimes beneficial, and a tepid or warm 
bath sometimes exercises a calmative and soporific effect. 
If the temperature is pers^tently over 103 , frequent resort 
to tepid sponging, cold sponging, an ice pack, or the tepid 
or even cold bath is indicated. An ice-cap to the head is 
occasionally useful in the same way. Quinine may be given 
in one-, two- or three-grain doses three times a day, anti- 
pyrin, one of the latest antipyretic drugs, may be given to 
children, between six and ten, in doses of three to five grains. 
It lowers the temperature, sometimes produces profuse 
sweating, and may possibly be of service occasionally. But 
it sometimes produces severe depression, and even collapse. 
Two other remedies have been introduced of late — sulphate 
of thalline and acetanilide or antifebrin. Steffen and others 
have used the former extensively, and have seen no ill 
results, but untoward symptoms have been reported in one 
or two instances. It appears to be a certain antipyretic. 
Dr. Goodhart has given it in doses of one to three grains, 
repeating it, as Steffen directs, after an hour if the tempera- 
ture should not fall. But he more often prescribes acetan- 
ilide, as it appears to be practically free from any risk. It 
may be given in similar dose to thalline. He generally 
gives a grain to begin with in children of six or seven, and 
increases this if the effect is but little. Acetanilide is very 
insoluble — it may be given as a powder, which is tasteless, 
or dissolved in rectified spirit. None of these remedies 
appear to have any effect in curtailing the duration of the 
disease; but it is possible that, by keeping the temperature 
at a lower average level, some good may result. At 
present this has not been very apparent. 



TYPHOID FEVER. 34 1 

For abdominal distention there is nothing so good as 
turpentine or terebene. Either of these may be mixed with 
mucilage of tragacanth, syrup, and cinnamon-water; or 
mixed with butter and put at the back of the tongue or 
dropped on sugar. In this way, five drops of the oil of 
turpentine or two or three of terebene may often be taken 
without exciting much resistance. Hillier recommends an 
enema of assafcetida. 

For diarrhoea, five drops of tincture of opium with an ounce 
of starch-water by enema, is the plan of treatment which 
seems most generally successful ; but two or three grains of 
Dover's powder, given internally once or twice in the twenty- 
four hours, will often be equally efficacious. A moderate 
diarrhoea, two or three evacuations in the twenty-four hours, 
is not to be checked. Severe diarrhoea is generally associ- 
ated with abdominal distention, and indicates severe ulcera- 
tion, and although it is the general practice to give opiates, 
it is preferable to combine them with such other drugs as 
may have an antiseptic effect upon the surfaces of the ulcers, 
such as turpentine, borax, etc. It is -further advisable in 
such cases to see to the quantity of food taken. The diar- 
rhoea may be moderated by reducing the quantity of milk, 
and giving thin broth of chicken, veal, or mutton. Brand's 
or Cybil's essence of beef gives a large amount of nourish- 
ment in a form which one supposes is absorbed from the 
upper part of the intestines, and cannot leave much behind 
to worry the ulcerated surface below. Bismuth subnitrate 
and ipecacuanha wine are also of use, and so also the tinc- 
ture of krameria, extract of logwood, and chalk mixture. 

For the bronchitis, a little ipecacuanha wine, with tr. opii 
camph. and syrup of tolu, may be given. In cases of car- 
diac weakness or renal congestion, caffeine may be found 
useful ; Jacobi thinks more highly of it than of digitalis for 
heart failure. It may be given in grain doses to children of 
29 



342 DISEASES OF CHILDREN. 

six or seven years, and may be combined with three or four 
grains of benzoate of soda ; a solution is thus formed which 
is a powerful diuretic. 

As regards treatment by the bath, Henoch makes some 
very practical remarks. The effects of cold bathing are 
more pronounced in children than in adults, and conse- 
quently the first bath is, in some cases, an experiment, and 
it may be followed by a gradually falling temperature, until 
a condition approaching collapse results. This may be ob- 
viated by the administration of wine before and after the 
bath, but more particularly by trusting to tepid rather than 
cold bathing, and by not prolonging the immersion beyond 
six or eight minutes. The American editor prefers tepid 
sponging to the full bath. 



PART III. 
GENERAL DISEASES NOT INFECTIOUS. 



i. Malarial Fever. — Ague is uncommon in children, and 
its behavior is sometimes peculiar. For this reason it is 
likely to be overlooked. It may occur even in infancy, and 
enlargements of the spleen have been found at birth which 
have been supposed to be due to the malarial poison. But 
the disease is more usually seen in those of four years old 
and upward. It may sometimes occur in typical form, with 
cold, hot, and sweating stages. But as a rule well-marked 
rigors and definite periodicity are absent. Dr. West states 
that the place of rigors is taken by a condition of extreme 
nervous depression, sometimes by convulsions. As other 
peculiarities he notes the long continuance of the hot stage, 
the absence of any distinct sweating stage, and a continuous 
form of malaise, and even pyrexia. This description will 
show how easily malarial fever might be mistaken for some 
continued fever of doubtful nature; an error all the more 
likely from the infrequent occurrence of the one disease, and 
the very common occurrence of the other. The acme of 
the pyrexia, as in adults, may be very high (105 ), and pos- 
sibly this feature might in some cases convey a hint of the 
true nature of the disease. But more important than these 
anomalies of the more typical symptoms is the necessity of 
recognizing that malarial anaemia is not uncommon — some- 
times associated with enlargement of the spleen, sometimes 

343 



344 DISEASES OF CHILDREN. 

not — and that extreme anaemia may exist without any his- 
tory of preexisting fever. Anaemia is a characteristic 
symptom of ague at all ages, but it rarely reaches such an 
extreme in adults as'is sometimes the case in childhood. It 
is said to come on very rapidly. Enlargement of the spleen 
is a common disease in children in the malarial regions of 
the tropics. The spleen under such circumstances will 
attain an enormous size, and many children die from this 
cause. 

As above stated the first and last stages of the disease 
are frequently not as marked as in adults. The first stage 
is often overlooked by the parents, but when the rigor is 
absent there are slight tremors or the face becomes shrunken 
and pallid and the lips and finger-tips livid. The second 
stage is much prolonged, while the third is usually very 
short and sometimes altogether absent. During the inter- 
val between the paroxysms the child does not regain its 
usual buoyant spirits, but remains dull, fretful, and feverish. 
After the fifth year the disease presents about the same 
features as it does in adults. 

Diagnosis. — This must be arrived at first of all by bearing 
in mind the possibility of the occurrence of ague, and next 
by inquiring into all the circumstances of the case. There 
are no means by which to distinguish the enlargement of 
the spleen due to ague from that due to other causes. But 
as regards the anaemia, the skin has a simple or sallow pal- 
lor with a bluish tint of the lips, which may help to suggest 
the nature of the case. 

Prognosis. — Ague is difficult to eradicate thoroughly at 
any time of life. With this qualification, it answers to the 
same remedies as in adults. But the enlargement of the 
spleen may be troublesome and slow to disappear. 

Treatment. — Quinine and arsenic are the remedies to 
employ. Quinine is usually taken readily by children — it 



RICKETS. 345 

may be given in sweetened milk or with syrup and liquorice, 
or in the form of lozenges, as the quinine chocolates now 
used in America. Arsenic should be commenced after 
quinine is discontinued. From two to five drops of Fowler's 
solution may be given in syrup of orange and water, three 
times a day after meals. It is often good to combine it 
with iron. With the syrup of the lacto-phosphate of lime 
and iron it makes a good tonic. 

2. Rickets is one of those diseases for which familiarity 
often breeds a certain amount of contempt in the student's 
mind. "Only a case of rickets" is not infrequently his 
mental attitude in regard to it. Nevertheless, it is a disease 
of much interest. It occurs most frequently among the 
poor, the ill-fed, and the badly housed of our large towns, 
and it is a cause of heavy infant mortality through bron- 
chitis and its allies, while yet it is one of the most pre- 
ventable of diseases. 

Etiology. — As with many other diseases, so soon as we 
come to discuss its causes, although the evidence on the 
main points is unmistakable, there are yet subsidiary ele- 
ments which, while they are less certain, have, sometimes, 
in the heat of controversy, been allowed to obscure the 
light we have. Rickets is a diet disease, due to the pro- 
longed administration of indigestible, and for the most part 
of starchy, food. It has been said, indeed, that rickets can 
be produced at will by the copious admixture of starch 
with the milk at a time when the child is unable to digest 
it. This is hardly so. In the larger number of cases 
atrophy and the death of the child are brought about by 
bad feeding. In some, and these also very common, Na- 
ture, so to speak, saves the ship from wreck, and the child 
is left to drag along in the sadly deteriorated condition we 
know as rickets. This much all will allow. It is only 
when we come to discuss the question as to what other 



346 DISEASES OF CHILDREN. 

influences are at work in the production of the disease that 
any uncertainty exists. It must be admitted that a deteri- 
orated condition of health on the part of the mother, either 
during gestation, or while suckling the infant, is only too 
likely to predispose to or perhaps actually produce rickets. 
It is true, as Dr. Eustace Smith states, that unduly pro- 
longed suckling may induce rickets. ■ Again, one can 
readily admit — the burden of proof surely lies on him who 
would not do so — that bad air, ill-ventilated rooms, want 
of cleanliness, are potent abettors of the disease ; while 
syphilis also, in that it produces a much impaired state of 
nutrition often extending over many months, may surely 
help in the same direction. 

These are all questions which will have to be entertained 
in individual cases. These various elements of bad hygiene 
will then need to be very carefully appraised, and the direct- 
ness of success in treatment will no doubt depend much 
upon whether this be done well or ill. But the general 
question involved is untouched by them ; and rickets re- 
mains essentially a diet disease, unless, indeed, such a radi- 
cal hypothesis be accepted as that of M. Parrot, that rickets 
is a manifestation of infantile syphilis. 

We believe, however, that rickets exists for the most 
part independently of syphilis, and that it is not in most 
cases ameliorated by mercurials or iodide of potassium. 

The arguments in favor of its dietetic origin are, shortly, 
these : Changes in many respects like it are found in the 
lower animals kept in confinement and under artificial con- 
ditions as regards their food. It is a disease of all large 
towns, more or less — that is to say, in proportion as the 
population increases, over-crowding occurs and the means 
of subsistence become more costly ; then hand-feeding, and 
cheaper, less troublesome, and less valuable foods are sub- 
stituted for milk, and so rickets is produced. Although 



RICKETS. 347 

sometimes called the English disease, it is by no means 
confined to that country, being frequently met with in most 
of the large continental cities, and often occurring in the 
United States. Lastly, it is a disease found, to say the 
least, in overwhelmingly large proportions, in hand-fed in- 
fants. Dr. Buchanan Baxter made some most careful in- 
quiries on this point among the out-patients at the Evelina 
Hospital, and the result was that no less than ninety-two 
per cent, of the whole number had been given farinaceous 
food before the age of twelve months. The time of life at 
which the disease is met with forms an important element 
on this head, and Dr. Goodhart has analyzed 141 of his 
own cases, to show the time of life at which the disease 
occurs : — 

5 7 8 9 10 11 12 18 2 years 2^ , fi T , 

m. m. m. m. m. m. m. m. and under, years. a - /z T J 

3 1 3 2 5 6 11 36 26 19 13 2 6 5 3 141 

Sixty-eight were boys, seventy-three girls. 

Dr. Gee* gives much larger numbers than these. Of 635 
cases (365 boys, 270 girls) 32 were under six months, 144 
from six to twelve months, 183 from twelve to eighteen 
months, 133 between eighteen months and two years, 116 
in the third year, and 27 in the fourth year. And he 
further states that thirty per cent, of sick children under 
two years of age are rickety. 

This table only gives the age at which the child was 
brought for treatment. In most cases the onset of the dis- 
ease must have ante-dated the attendance by a considerable 
period. But it shows how large a proportion of cases 
occur from ten months to two and a half years — that is to 
say, from weaning onward through the period of dentition. 

It may be added here that some authors have contended 

* On Rickets, " St. Bartholomew's Hospital Reports," vol. IV, p. 69. 



348 DISEASES OF CHILDREN. 

for the existence (i) of foetal rickets, (2) of rickets at birth 
(congenital rickets), (3) of the rickets at the time of life here 
spoken of, and (4) of late rickets. As to foetal rickets, most 
authors consider it to be a form of cretinism ; and the ex- 
istence of congenital rickets is doubtful, though possible. 
All agree that rickets is rare during the first two or three 
months of life. 

While making these somewhat dogmatic statements it 
must be borne in mind that there is no single fact in con- 
nection with rickets which has not been at some time or 
another, and which is not now, disputed by this authority or 
that. There are some who think the disease a diathetic 
one — one, that is to say, passed on from parent to child, in 
large measure independent of, and incapable of production 
by external agencies alone. Some observations of Ritter 
von Rittershain show that rickety children frequently come 
of mothers who still bear traces of having suffered from a 
similar disease. It is also said, and the same author, to some 
extent, countenances this view, that tubercle is associated 
with rickets. Trousseau held that the two were mutually 
exclusive. But there can be no doubt that tuberculosis is 
not uncommon as a sequel to rickets, though, as Hillier 
says, the two conditions seldom go on actively at one time. 

Others hold, like ourselves, that it is dietetic ; others, 
still more rigorously, that it is not only dietetic in a general 
way, but due to the administration of starch in particular ; 
others, again, lay stress on feeble health in the mother 
during gestation or lactation ; others upon bad air, want of 
light, insufficient clothing, want of cleanliness, etc., and so 
on. Arguments quite worthy of consideration have been 
used for and against all these hypotheses by observers, of 
whom it will be enough to say that their names include 
some of the brightest ornaments of medicine and pathology 
in this and other countries. But upon a reflective study of 



RICKETS. 349 

much that has been written, the short summary given seems 
to be a fair and reasonable one, and it is probable that all 
of the causes mentioned aid the main one — a faulty diet — in 
producing the disease. 

Symptoms. — Rickets is, for the most part, a slowly pro- 
gressing general change in the tissues and the viscera, 
which runs an insidious apyrexial course. In the earlier 
stages of the disease the symptoms are somewhat vague. 
Diarrhoea, restlessness during sleep, and a tendency to 
throw off the bedclothes ; profuse sweating of the head, 
neck, and chest ; causeless crying when the child is moved, 
and a flabby condition of the muscles of the arms and legs, 
combined often with an excessive amount of subcutaneous 
fat, are among those which at first are the most noticeable. 
Later, the ribs become beaded, the wrists, knees, and 
ankles enlarge (Dr. Marshall has even noticed the knuckles 
affected), the shape of the head becomes characteristic, the 
nervous system irritable, and, in the latest stage, the child 
wastes, the ribs fall in, the spine and long bones curve, the 
liver and spleen become enlarged, and death may happen 
from bronchitis, broncho-pneumonia, convulsions, etc. But 
the symptoms must be considered in rather more detail. 

The head in rickets is often characteristic ; the veins 
upon the forehead stand out full of blood ; the fontanelle 
bulges and is unduly open ; and the head is elongated from 
back to front, and its posterior segment enlarged. The 
head appears flattened in the temporal region, and the 
forehead, although overhanging, is not expanded, the gen- 
eral form being square. Thus, in several points, it differs 
from the hydrocephalic skull, which tends to assume a 
globular shape; the temporal fossae bulging in place of 
flattening, the forehead being expanded, and the frontal 
bone opening gradually upward to the globular and bulg- 
ing anterior fontanelle. Rickets may be combined with 
30 



350 DISEASES OF CHILDREN. 

hydrocephalus ; but apart from this, the rachitic skull is 
latterly compressed, with prominence in the region of each 
frontal and parietal eminence. The cause of this has been 
much discussed ; some attribute it to the fact that the child 
lies much on its back. By thus subjecting the occipital 
bone to pressure, the posterior part of the skull becomes 
flattened, and the brain is pressed forward against the 
frontal bone. This may be in a measure true, but it is also 
to be remembered that rickets is a disease which begins 
comparatively late — not till some months after birth — and, 
therefore, not until the centres of ossification in the skull 
have had a fair start. The regions of the frontal and pari- 
etal eminences are then comparatively well protected, and 
the growth of the brain will go on with less difficulty by 
lengthening the skull from before backward, and also by 
pushing outward as a whole the lateral halves of the skull 
cap. Moreover, the interfrontal suture unites before the 
end of the first year, and, should the rickety condition 
supervene at a later date — as is probably not uncommon — 
the growth of the brain will then more readily proceed 
backward, and, by widening out of the parietal eminences, 
a head with a small square forehead and large posterior 
segment would be produced — the shape, in fact, which is a 
characteristic of the skull in many a case of rickets. 

It may be added that the brain is not exempt from laws 
which apply to other parts, and that — like the foot of the 
Chinese woman which, taking its shape from the boot, 
grows best along the lines of least resistance. Can any- 
thing of greater significance be suggested, where convul- 
sions of varied kind form one of the chief features of the 
disease ? It can hardly be a matter of indifference whether 
the growth of the brain is allowed to proceed as it should 
do, or whether by an early closure, say of the frontal or 
sagittal suture, the posterior parts are made to develop in 



RICKETS. 351 

disproportion to the front, or some part of the latter is 
placed under disadvantage. The size of the skull has 
usually been said to be increased in rickets, but Ritter von 
Rittershain, on the ground of careful comparative meas- 
urements, denies that there is any enlargement. The head 
often appears to be large, but this is due to the peeky face, 
the stunted limbs, and bad nutrition. Trousseau taught 
that the large skull went with precocity ; but if the skull 
be not really enlarged, that contention falls to the ground ; 
and if it be, the precocity is of a very shallow kind in most 
cases — it is more true to hold, with Gee, that the brain is 
usually dwarfed. Jenner ascribes the prominent forehead 
to infiltration of the anterior lobes of the brain with albu- 
minoid materials, others would say to hypertrophy of the 
brain. This must, however, be a very rare condition, 
whereas the prominence of the forehead is a very common 
feature of the disease. The explanation given, namely, that 
the brain pushes the segments of the skull backward and 
forward, is more satisfactory for the majority of cases; while 
in some it is accounted for by an exuberant growth of soft 
bone on the frontal eminences. 

Hydrocephalus is said by some to be a frequent associate 
of rickets. This is not proven. The fontanel le may remain 
widely open long after the period when its closure should 
be complete (this is given by Eustace Smith as the end of 
the second year, but in healthy children very little of a 
fontanelle should remain after the end of the first year), 
and it may bulge unduly, and frequently does so in rickets, 
but these things do not necessarily mean hydrocephalus. 
At the same time, the onset of this disease would seem to 
be likely enough, for any delayed ossification of the skull 
to some extent predisposes toward the occurrence of a 
congested brain, or of hydrocephalus. 

Craniotabes, first described by Elsasser in 1843, has till 



352 DISEASES OF CHILDREN. 

lately been held to be a sign of rickets. M. Parrot and 
others have called this doctrine in question, and consider 
the complaint a sign, not of rickets, but of congenital syph- 
ilis. Craniotabes, or wasting of the skull, is a condition of 
softening of the bones, particularly of the occipital, by which, 
under moderate pressure from the finger, the bone caves in- 
ward with a crackle like that of stiff parchment. It is of 
two kinds : in very young infants the bones of the skull 
will yield under pressure and sometimes crackle, but this 
is not a diseased condition. The true disease generally 
exists in localized patches. It is said to occur in thirty to 
forty per cent, of all cases of rickets, and is found to perfec- 
tion from six months after birth onward. It is an open 
question how far this condition is due to uncomplicated 
rickets, and how far to syphilis; but it is a remarkable fact 
that, since the question was mooted, some very weighty 
evidence has been produced in favor of its association more 
with syphilis than with rickets. Dr. Thomas Barlow and 
Dr. Lees collected ioo cases of craniotabes, and have 
published* the results of a most careful inquiry upon its 
relationship both to syphilis and rickets. From it they 
conclude that forty- seven per cent, of the total are almost 
certainly syphilitic ; and to this may be added the observa- 
tion of Dr. Baxter,f that of the twenty-three per cent, of 
craniotabes in rachitic children, seventy-five per cent, were 
syphilitic. The author's opinion — and the editor can con- 
firm it — inclines in the same direction. For a long time Dr. 
Goodhart has examined for craniotabes among rachitic 
children, and, finding it so seldom, he is disposed to think 
it is far less common than has been taught ; but then, 
being engaged at the same time on other observations upon 

* " Path. Soc. Trans.," vol. xxxu, p. 323 et seq. 
f Op. cit., p. 361. 



RICKETS. 353 

congenital syphilis, all cases that showed any traces or sus- 
picion of that disease, even if associated with rickets, were, 
no doubt, passed into the syphilitic group, and thus may 
have escaped notice. Certainly, in such cases as he has 
known in recent years, craniotabes has most often been 
seen, either in well-marked cases of congenital syphilis, or 
in cases in which the suspicion of the existence of that 
disease was strong; but there is still a proportion of cases 
in which no such taint can be shown to exist, and he sup- 
poses it to be one of those conditions for which a com- 
bination of circumstances, if not necessary, at least is most 
favorable to its production. 

In this regard it is important to remark that experienced 
observers state that craniotabes is almost invariably asso- 
ciated with laryngismus stridulus. Now this condition 
is universally admitted to be almost always due to rickets ; 
so that, if the two are thus closely associated, the fact is 
clearly in favor of the rachitic nature of craniotabes. The 
editor, however, has examined many cases of rickets and 
has never been able to detect craniotabes, though laryngis- 
mus stridulus was present in some of the cases. 

The skull of a child affected with craniotabes shows shal- 
low depressions at the diseased parts, smoothly beveled off 
into the surrounding bone. The depressed areas may be so 
numerous as to give the inner table a somewhat trabeculated 
appearance. The thin layer of bone which covers in the 
depression is that which gives the crackle as it bends inward 
on pressure. In some cases the thinning is more general, 
involving, perhaps, the entire occipital bone ; in others, the 
local thinning is considerable, and may go on to the forma- 
tion of a number of membranous opercula. In other cases, 
again — and the real nature of such is still open to question 
— there is much tendency, not only to thinning and soften- 
ing, but to the formation of new bone, in most cases leading 



354 DISEASES OF CHILDREN. 

to the production of a velvet-pile-like layer of osteophyte 
over the surface of the calvaria between the sutures and the 
centres of ossification. In this way the sutures come to form 
furrows, and the natiform skull is produced, and sometimes 
the bone formation may be so active that the skull may 
reach a thickness of half an inch or more. The new bone 
is very soft in all these cases, it can be cut with a knife, 
and is of a peculiar claret color, from the amount of blood 
it contains. Many consider this condition of the bones of 
the skull to be a sign of congenital syphilis. It is cer- 
tainly frequently found in syphilitic infants — in infants in 
whom other evidences of rickets, though not absent, are 
yet of the slightest. Nevertheless, one cannot altogether 
exclude rickets from, at any rate, an occasional share in its 
production. 

Other signs of rickets are found in the epiphysial extremi- 
ties of the long bones and in the ribs. In these the ossi- 
fying layer of cartilage at the junction of the epiphysis with 
the shaft, or in the case of the ribs at the junction of the 
costal cartilage with the bone, becomes swollen — sometimes 
enormously so — and thus is produced a characteristic swell- 
ing of wrists and ankles and a beading of the ribs. These 
symptoms, although present in most cases, are by no means 
remarkable in many. A child maybe very rachitic as 
regards its head and dentition, and perhaps show a dis- 
torted thorax, enlargement of the spleen, and even curva- 
ture of its bones, while yet there is but little enlargement 
either of the ends of the ribs or of the radius or tibia. 

The bones are soft in rickets, and thus are occasioned 
sundry characteristic distortions of spine, thorax, pelvis, and 
long bones. In the thorax a double curve is assumed, the 
ribs fall in at their junction with the costal cartilages, and a 
vertical depression of considerable extent is produced in 
such parts of the thorax as are not supported by the solid 



RICKETS. 355 

viscera. The abdominal viscera prevent the falling in of 
the lower part of the chest ; the lateral parts of the upper 
segment fall in considerably, while the sternum becomes 
rounded and prominent, and the antero-posterior diameter 
of the chest becomes the dominant one. 

Some have distinguished between this, the chest of the 
rickety child, and the distortion due to other causes, such 
as atelectasis, or non-expansion of the lung. In the latter 
the ribs yield generally from their angles forward, and the 
transverse section of the chest becomes of a peg-top or angu- 
lar shape, from the sternum becoming carinated. It must 
be confessed, however, that there is much difficulty in sepa- 
rating the two distinct classes of cases. On a priori grounds 
it may be argued that the softened bone curves, not only 
at the epiphyses, but also generally in its length ; there is 
ample evidence that it actually does so ; and there seems 
little reason why the ribs should not thus yield. The worse 
the rachitic condition, so much the more yielding will there 
be, and the lateral grooves will then be pronounced. In 
milder cases the recession of the chest-wall will be less, and 
the chest will approach the angular type. Moreover, it is 
by no means certain that this shape does not represent a 
partial obliteration of the more marked distortions. It is 
much more common in children of six, eight, or ten years. 
The grooved chest is the common type of infancy. It is 
certain that, as the child grows and the bones harden, the 
deeper dip of the ribs at the costo-chondral articulation 
gradually expands again ; while the antero-posterior expan- 
sion of the lung is in a measure permanent, and tends to 
perpetuate the prominence of the sternum. 

In the -pelvis we observe the same conditions. The pel- 
vis of mollities is beaked, or Y-shaped, that of rickets is 
contracted in its antero-posterior capacity by the sacral 
promontory being unduly prominent. In extreme cases of 



35^ DISEASES OF CHILDREN. 

rickets, when the body weight has been unduly thrown 
upon the pelvis, the acetabula may be forced backward into 
the pelvis, and a beak be produced by the symphysis and 
pubic bones. The femora and the tibiae bow outward and 
forward ; each radius and ulna curves outward ; and in 
extreme cases the natural curves of the clavicles become 
much exaggerated. These conditions go with, or some- 
times may be replaced by, an unnatural relaxation of the 
ligaments, particularly at the knees, and thus cause knock- 
knee and bandy-legs that are so often seen in late cases of 
rickets. 

A good deal of discussion has been carried on as regards 
the cause of all these deformities. Some have contended 
for muscular force acting upon soft bones ; others for simple 
weight — the bones, not being strong enough, yielding under 
the weight they are called to support. Both these forces are 
probably entitled to some consideration ; but the theory 
which attributes the curvatures to undue weight is no doubt 
the more important, and most of them may be understood 
and explained by a consideration of the direction in which 
the force has acted. In one case it may be the weight of 
the body in walking ; in another, that of one part of the limb 
upon the remainder, in certain recumbent postures. In the 
arms it is due to those parts being used as a help to pro- 
gression, the child moving on all-fours. In the thorax some 
have attributed the distortion to a combination of softening 
of the bones, with collapse of the lung, which is a frequent 
associate and consequence of rickets ; others to softening 
of the bone, and a yielding under the inspiratory pull of the 
muscles. There can be no doubt, however, that the de- 
formity of the thorax is almost constantly associated with 
bronchitis and atelectasis, and that in the bones of the spine 
and extremities curvatures may reach any extreme form in 
such as have not been allowed to walk or sit up unduly. 



RICKETS. 357 

Another important point as regards the rachitic skeleton 
is that the bones are stunted in their growth, and in extreme 
cases the child may be greatly dwarfed by this means. 

The muscles all over the body are often excessively pain- 
ful. Pressure is very painful to these children, and they 
will often cry bitterly whenever they are moved. This con- 
dition may be present even before the changes in the bones 
are at all pronounced. Some children are described as 
screaming whenever any attempt is made to move them ; 
but it is probable that in such there is some periosteal 
lesion. 

Convulsions, tetany, and laryngismus stridulus are in a 
very large number of cases associated with rickets. Indeed, 
so commonly is this the case, that laryngismus particularly 
is thought by many to be always rachitic. 

Zonular cataract, a condition in which some of the strata 
of the lens between the nucleus and the cortex become 
opaque leaving the margin and central part clear, is a lia- 
bility which attaches to infantile convulsions, and therefore 
to rickets. Why this is so, we know not. 

The lymphatic glands all over the body become slightly 
enlarged, and although it cannot be said to be common if 
we compute the entire number of rachitic children, this or 
an enlarged spleen and anaemia should always direct our 
attention to rickets as one of the causes. 

Dentition is much delayed in rickets. A child of two 
years old may perhaps have no more of the milk teeth than 
the incisors and a molar or two, and these all more or less 
decayed. Delayed dentition is a valuable sign of the more 
moderate forms of rickets, which might otherwise pass un- 
noticed. The enamel of rachitic teeth is bad ; the teeth 
are notched, or have horizontal ridges, and break away 
nearly down to the gum, where they appear as black jagged 
stumps. These conditions are not peculiar to rickets, and 



358 DISEASES OF CHILDREN. 

may occur as the result of any severe or prolonged state of 
ill-health in infancy. 

The urine is said to contain too little urea and uric acid, 
and an increase of the earthy phosphates ; though this state- 
ment has been called in question by Rehn and Seemann. 

Complications. — The chief complications are bronchitis 
with atelectasis, and diarrhoea. The association of rickets 
with scurvy is important, but not common. The occur- 
rence of bronchitis is readily explained by the softened ribs 
and the distorted chest; these entail atelectasis and em- 
physema, which in turn lead to bronchitis ; the disease in 
the tubes, by still more preventing the ingress and egress 
of air, increases the amount of collapse, and the increasing 
collapse tends to aggravate the catarrh, and the collection 
of a muco-purulent secretion in the tubes. The causes of 
the diarrhoea can be less precisely stated ; but in an un- 
healthy child, with unhealthy secretions, congested viscera, 
diseased lymphatic glands, and severe disease of the bones 
— which are, at this time of life, most important elaborating 
organs for maintaining the blood at a normal standard — 
the existence of diarrhoea is at any rate no cause for 
surprise. 

Scorbutic or acute rickets will be alluded to under the 
head of scrofula. 

Morbid Anatomy. — If we take the epiphysial end of a 
moderately rickety bone— of the rib, for example — and 
make a section through the length of it and its adjacent 
cartilage, comparatively healthy bone is seen on the one 
side, healthy cartilage on the other, and between the two a 
layer, more or less thick according to the severity of the 
disease, of bluish or pearl-gray translucent cartilage. The 
margin of this toward the cartilage is regular, but streaked 
with large vascular lines ; toward the bone it is irregular, 
and sometimes so much so as to intersect the bone immedi- 



RICKETS. 359 

ately adjacent, and to appear as islands of cartilage, with 
vascular and calcareous points scattered about. On further 
examination, the adjacent layer of bone is seen to be paler 
or yellower than normal, and more porous. The superficial 
layer of the periosteum is unaffected — it can be peeled off 
the bone beneath, leaving a continuous surface; but beneath 
it, on the bone adjacent to the cartilage, there is more or 
less of a vascular soft material, prolonged upon it for a short 
distance, and imperceptibly lost as the cartilage recedes. 

The pearly layer of swollen cartilage causes the beading 
of the ribs and the enlargement of the ends of the long 
bones so well known in rickets. As regards the former, it 
is always more marked on the pleural aspect, because the 
thoracic walls bend inward at this point, and make a 
knuckle toward the lung. The bone elsewhere is softer 
and more porous than usual, and the fatty appearance of 
the medulla is replaced by one of a more vascular sort. 

Under the microscope, an excessive activity of the carti- 
lage is observed. The cartilage cells become swollen and 
largely increased in number ; but instead of making good 
bone, a process of calcification goes on in them, and the 
interstices between them become filled with a vascular mar- 
row instead of with natural bone. These medullary spaces 
are continuous with the channels in the shaft, and thus is 
formed a spongy tissue, very vascular but with little bone in 
it. A similar process goes on in the vascular tissue under 
the periosteum : osteoblasts maybe seen in all parts, though 
there is but little bone. 

The essential features of the bone changes in rickets, 
therefore, are excessive activity of growth of that cartilage 
which makes for bone, and the production of a large quan- 
tity of vascular embryonic tissue, or medulla. It can then 
be readily understood that, so soon as the rachitic condi- 
tion — whatever it may be — is neutralized, all things are in 



360 DISEASES OF CHILDREN. 

favor of rapid ossification. This is what actually happens 
in many cases ; the epiphysial lines ossify so quickly that 
the growth of the bone is curtailed by the perfection of the 
repair, and thus bygone rickets is likely to be represented 
by a stunted but unusually hard and ivory-like bone. As 
implied elsewhere, the rachitic process is either not always 
of the same intensity, or it varies somewhat in different 
regions ; and in the skull and spine there would seem at 
all times to be a probability of the production of more 
.growth than in other parts, although still a soft spongy 
bone of indifferent quality. As regards the process of 
repair in these regions, it is difficult to speak ; but from the 
not uncommon occurrence in adults of dense ivory-like 
skulls, and spines with eburnated surfaces, which want an 
explanation, it is probable that a similar course is pursued, 
in at least some, to that which goes on in the bones of the 
extremities. 

From what has been said, it follows that there must be 
a considerable alteration in the chemical constituents of 
rickety bones, and analyses show a considerable deficiency 
of the earthy salts. 

Of other morbid appearances found in rickets not much 
need be said, as they are described in other places in this 
book — indeed, not much can be said, so little is known 
about them. Changes in the brain have been described, 
such as albuminoid disease and chronic cerebritis. Both 
conditions must be very rare. The actual frequency of 
hydrocephalus, again, as a post-mortem occurrence — ex- 
cept as following upon convulsions and some organic dis- 
ease, and possibly in this way dependent upon rickets — Dr. 
Goodhart thinks has been overestimated, and that the 
apparent frequency must have been deduced from such 
clinical features as distention of the fontanelle and fullness of 
the vessels of the scalp. But the meaning of these symp- 



RICKETS. 361 

toms alone in any case is decidedly equivocal, as will be 
shown under the head of hydrocephalus. 

The lymphatic glands undergo some change, probably of 
a fibroid nature, and reveal this by an indurated, scarcely 
enlarged condition. It is supposed, though without ade- 
quate proof, that this change is of a similar nature to that 
which the spleen and liver undergo. The albuminoid dis- 
ease of all these viscera had been described as a glue-like 
change peculiar to this disease ; but the observations of Dr. 
Dickinson and others (see Diseases of Spleen) make it clear 
that the actual change in the viscera — and it is more com- 
mon by far in spleen than liver, and, the author thinks, than 
in lymphatic glands — is an increase in the fibroid material 
which constitutes the connective tissue of the organs, and it 
differs in no respect from that of the chronic enlargement 
of the viscera met with sometimes in ague, etc. The disease 
of the spleen, though it is more frequent than that of the 
liver, cannot be called common. Dr. Goodhart has notes 
of only forty-four cases, and in twenty-four of these the 
rachitic nature of the general ailment was doubtful. It 
would seem, therefore, that the changes in the viscera can 
hardly be an essential of rickets, and probably Gee is correct 
in considering them due to some preexisting conditions, 
which, perhaps, they share in common with rickets. 

The condition of the blood in rickets has received but 
little attention. Chemically, it has practically received none. 
Dr. Goodhart has made numerous microscopic observations 
upon the blood of rachitic children, and the changes in it 
are certainly remarkable. In some there is a simple defi- 
ciency of corpuscles ; in some a deficiency of coloring 
matter ; in some the blood is crowded with a granular de- 
tritus ; and in some the corpuscles are represented by four 
or five different sizes. We are surely justified in assuming 
that these appearances indicate immaturity, poverty, and 



362 DISEASES OF CHILDREN. 

increased waste of the blood, when such are the exact 
conditions we should expect from what we know of the 
surroundings among which rickets finds its home. These 
must produce an inferior quality of the circulating fluids, 
and an inferior quality of blood will produce a deteriorated 
bone ; the converse also holds true — bad bone will make 
bad blood, and the lymphatic glands and spleen are there- 
fore doubly likely to suffer some chronic changes of the 
kind that are known to keep company with blood diseases. 

Pathology. — Such being the morbid anatomy of rickets, 
what opinion can be arrived at as regards its pathology ? 
One point in the histology of the disease seems to be 
preeminent — that the departure from the normal is one 
of perverted development. It is a disease only in so far 
as the material formed is not the best suited to the require- 
ments of the body. This is important, for some patholo- 
gists are inclined to put all soft bones into one cate- 
gory. For such, rickets, mollities ossium, and the senile 
fragility of bone, which is not uncommon, are all related to 
each other ; differing chiefly in the age of the affected per- 
son — for whom, perhaps, the missing link to bridge the two 
periods of life may be found in what has been called " late 
rickets." Surely this is disproved by a study of their 
morbid anatomy. Rickets is clearly an arrest of develop- 
ment ; -mollities is a degeneration of formed material. There 
can be no question that there is some truth in the remark 
that rickets can be produced by feeding an infant on starchy 
food before it can digest it. No known condition of bad 
feeding will produce mollities ossium ; diet a case of osteitis 
deformans how we will, no impression is made upon the 
disease, and both this disease and mollities are quite beyond 
our knowledge and our power. 

Many suggestions have been offered as to the cause of 
defective bone formation in rickets. Perhaps the most 



RICKETS. 363 

favorite one has been that an excess of lactic acid exists in 
the blood. Experiments were conducted upon animals by 
feeding them on phosphorus, while phosphate of lime was 
withheld from their food. This treatment produced rickets, 
it was supposed by the phosphorus acting as a stimulant to 
the would-be-bone, which was thus compelled to make 
bricks without straw. It is suggested that lactic acid, formed 
in the alimentary canal from milk and other food, may act 
in the same way, the materials for proper bone being want- 
ing. But no excess of lactic acid in the blood has ever been 
found. On the contrary, the latest observations make its 
presence extremely doubtful ; and the cause of the disease 
has by some been maintained to be a deficiency of hydro- 
chloric acid. The intimate pathology of rickets is still un- 
known. But if we dismiss the question, how the softening 
of bone is effected, there are facts in the disease which are 
remarkably suggestive in attempting to frame a pathological 
conception of the conditions which determine it ; and chief 
of these is this most remarkable fact, that rickets, qua rickets, 
invariably recovers if treated properly — that is, essentially, 
if the child be put upon a proper diet. There is, perhaps, 
no other argument of equal force in favor of the disease 
being due to something which is withheld — in favor, that is, 
of the disease being dietetic. 

Diagnosis. — When the bone changes are moderate the 
disease is frequently overlooked, and passes for mere back- 
wardness, weakness, etc. Rickety children are often 
plump in the earlier stages ; afterwards, they become flabby 
and wasted. Apart from such general considerations as 
these, two or three errors in particular have to be avoided. 
One, of mistaking inflammatory and sanguineous effusions 
beneath the periosteum for simple rickets, as has no doubt 
frequently been done under the name of acute rickets (see 
chapter on Scrofula). Another, of confounding the bone 



364 DISEASES OF CHILDREN. 

changes of congenital syphilis with those of rickets. And 
lastly, many children are brought for paralysis, and inability 
to walk and dangling legs, in whom the whole disease is 
rickets. There may, indeed, be a greenstick fracture due 
to this cause ; but apart from this, the pain and wasting of 
the muscles will produce a very complete inability to move 
the limbs, which may sometimes deceive an incautious 
observer. Bearing the fact in mind, a mistake can hardly 
arise. 

As regards the bone lesions of congenital syphilis, rickets 
— if we allow the nature of the changes in the skull to be 
an open question — is a cartilage producer, syphilis is a bone 
producer. Thus, syphilis produces more extensive and 
diffused thickening of the lower end of the diaphysis than 
does rickets. And further, the bone lesions of syphilis are 
destructive, leading to separation of the epiphysis from the 
shaft, and to the formation of abscesses. 

Prognosis. — This will always depend upon the extent of 
disease in the lungs and in the viscera. Given a case of 
uncomplicated bone disease, and it may be said almost in- 
variably to get well. On the other hand, splenic enlarge- 
ment, accompanied as it often is by a profound anaemia, will 
surely prove troublesome, and such a case may waste and 
die. Many such, however, do well eventually. The bron- 
chitis, with atelectasis and a distorted chest, is also a most 
serious matter. It is a great risk in itself, and it also pos- 
sesses a secondary risk in the liability that exists for the 
production of cheesy changes in the bronchial glands and a 
subsequent tuberculosis. 

Convulsions cause death in a large number of cases, 
although the risk may be much mitigated by keeping them 
under treatment. Laryngismus stridulus appears some- 
times to cause death, although it *is not always possible to 
be certain how far the fatal event has been caused by un- 



RICKETS. 365 

complicated laryngeal spasm, and how far by a general 
convulsion. 

Treatment. — In the first place, as will have been gathered 
from all that has gone before, rickets is a disease which may 
be prevented by the simple observance of such precautions 
as common sense would seem to dictate, without instruction. 
The child of a sickly or exhausted mother, with poor milk, 
will need additional food, according to the directions given in 
the Introduction ; the child that is still suckled at two years 
of age must needs be weaned, and food of good quality sup- 
plied to it. In addition to this attention to the food, it is 
probably of hardly less importance to insist upon the most 
perfect hygiene ; cleanliness, to the most minute detail, 
should be enforced ; a tepid bath should be given night and 
morning; there must be no stint in the changes of the 
child's under linen and napkins ; cleanliness must be ob- 
served in its bedding ; cleanliness in its food and feeding 
apparatus ; and its clothing must be thoroughly warm, yet 
not oppressive. The air the child lives in must be attended 
to. The garret near the sky, hot, dark, and stuffy, is not 
the place for the nursery. To prevent rickets, the rooms 
inhabited by the child must be well ventilated, not draughty, 
and though warm, never hot. Plenty of out-door exercise 
must be given, and if the neighborhood be unhealthy, the 
child should certainly, if possible, be removed to some dry 
and bracing place at the seaside or elsewhere. 

The treatment of rickets must follow the same lines ; but 
more than this, for the stomach of the child that has been 
fed on bread and butter, arrowroot, corn flour, potatoes, and 
water bewitched with the milk of one cow, must be educated 
back to the digestion of milk and such things as beef-juice 
and gravy. 

The diet for a rachitic child must vary with its age ; but 
seeing that most cases come under notice at eleven or 



366 DISEASES OF CHILDREN. 

twelve months old and upward, they are for the most part 
able to digest good milk well, and they have also arrived at 
a time of life at which, once in a day, they may take good 
gravy and custard pudding, broccoli, or cauliflower. Older 
children, of eighteen months or more, may have underdone 
pounded meat with well-cooked cauliflower and gravy. 
Eustace Smith gives a diet which cannot be improved. It 
is as follows : Breakfast ; a breakfast-cupful of milk, with 
one or two teaspoonfuls of Mellin's food dissolved in it. 
At eleven a.m. ; a breakfast-cupful of milk, alkalinized by 
fifteen drops of the saccharated solution of lime. Dinner at 
two ; a good tablespoonful of well-pounded mutton-chop, 
with gravy and a little crumbled stale bread ; or a good 
tablespoonful of the flower of broccoli, well stewed with 
gravy until quite tender, thin bread and butter, and toast- 
water to drink. Tea at six ; as at breakfast, or a lightly 
boiled yolk of an egg, if no meat has been given. 

But there are many rickety children who at two years of 
age have the development of a child of twelve months, and 
perhaps there is bad diarrhoea, vomiting, etc. In such 
cases the diet must be carefully adjusted to their condition. 
The amount of milk will perhaps have to be reduced, very 
likely in great measure replaced by the cream and whey 
previously recommended on page 99. In such cases as 
these, however, much reliance may be placed upon beef 
juice as an additional article of diet. This is made as for 
beef-tea : A quarter of a pound of meat is to be finely 
minced and soaked in a quarter of a pint of cold water for 
an hour; it is then strained and well pressed through 
muslin, and the resulting fluid is given, either cold or 
warm, by the bottle or spoon. Should any repugnance 
to it be manifested, it may be generally disguised in 
an equal quantity of milk, or it may be sweetened with 
a teaspoonful of malt extract. It should be freshly made 



RICKETS. 367 

each day, the quarter of a pint being distributed over 
the day. 

As regards medicinal treatment, saving the presence of 
special symptoms, no drugs are so successful as cod-liver 
oil and iron. The former should be given in doses, from 
twenty drops upward to half a drachm or a drachm three 
times a day, according to the age of the child. As regards 
the preparation of iron, some prefer the syrup of the iodide, 
others Parrish's food. The author prefers the, already fre- 
quently recommended, syrup of the lacto-phosphateof lime 
and iron, as he believes that children improve more rapidly 
with it than with other preparations. It may be given in 
half-drachm or drachm doses, well diluted. A teaspoonful 
of malt extract twice a day is another useful remedy, and 
orange juice or lemon juice, well sweetened, is also of ad- 
vantage, and particularly, perhaps, in such cases as have a 
scorbutic tendency. 

Some years ago phosphorus in small doses was recom- 
mended strongly. Dr. Goodhart tried it extensively, but 
saw no decided benefit from it. Kassowitz and various 
continental authorities have published extensive series of 
observations upon its value in recent years, and, although 
some claim for it considerable virtue, the testimony is still 
by no means unanimous. 

The diarrhoea of rickets should be first treated by a pre- 
liminary laxative of castor-oil or fluid magnesia. Subse- 
quently, if not relieved by the dieting and abstinence from 
starch, bismuth with chalk mixture may be given, with the 
addition, if necessary, of half a drop of tincture of opium 
to each dose ; or the following formula may be given : — 

]£ . Ex. hcematoxyli, gr. xx 

Vini ipecacuanha, Il^xx 

Vini opii, TT^x 

Mist, cretre, f 5 ij. t M. 

SiG. — A teaspoonful every four hours. 



368 DISEASES OF CHILDREN. 

Dr. Goodhart recommends this prescription : — 

}£ . Ammonite carbonat., gr. xxiv 

Potass, bicarbonat., 3 ij 

Ex. glycyrrhizse fl., f,^ ss 

Aquae q. s. ad f 5 iij. M. 

SiG. — One teaspoonful eveiy three cr four hours. 

The bronchitis, being of so much importance in these 
cases, must be treated carefully, even when it is of the slight- 
est. The child should then be kept in a warm room, the 
atmosphere of which is made moist by a bronchitis kettle. 
The bowels should be opened by an aperient, and warm 
fomentations (or poultices, if they be preferred) applied to 
the chest. If there be much mucus in the tubes, an ipe- 
cacuanha emetic should be given, and subsequently carbo- 
nate of ammonium, or other stimulating expectorant. 

Convulsions in any form must be kept at bay with bro- 
mide of potassium and chloral, while the general health is 
undergoing restoration. The ventilation of the nurseries 
requires special attention under these circumstances. More 
fresh air should probably be advised, and the body should 
be sponged with cold or tepid water night and morning. 
There are cases no doubt in which it is necessary to steer 
between Scylla and Charybdis, for while it is important to 
reduce the undue nervous irritability by such measures as 
these, it is equally necessary to avoid the occurrence of 
those bronchial attacks which are so fatal. 

The deformities of the limbs in rickets are to be pre- 
vented by keeping the child entirely off its legs until its 
bones become stronger. To insure this, long splints which 
render walking impossible must sometimes be applied ; but 
the less of splinting the better. One of the essentials of 
rickets is muscular failure, and it is above all things neces- 
sary, while the bones are hardening, to keep the muscles in 
as healthy a state as possible. For this end it is hardly 



RICKETS. 369 

possible to take too much pains ; and shampooing or fric- 
tion should be carried out regularly and thoroughly — the 
mother's or nurse's hand, well oiled, should gently rub and 
manipulate all the muscles of the trunk and extremities for 
half an hour regularly night and morning; and such stimu- 
lating treatment as salt baths and rubbing with a soft towel 
should be used in addition. 

As regards the remedy for the completed distortions of 
rickets, it is important to remember how common these are 
in childhood, how rare in adult life ; the inference being, as 
is well known to be the fact, that, except in extreme cases, 
Nature herself repairs the deformities as the bones grow and 
strengthen. Surgical aid, however, is often necessary, by 
the application in various forms of elastic extension, by 
splints, and, as a last resort, by the rectification of other- 
wise irremediable curvatures of the limbs, by osteotomy, etc. 

It is yet necessary to mention " late rickets " and " fcctal 
rickets!' But when, at the outset, the question arises, Do 
such diseases exist ? it will be apparent that not much is 
known about them. 

Late Rickets is a rare but well-recognized condition, in 
which the bones of children eight or ten years old soften and 
undergo extreme distortion. This form of disease, therefore, 
does not occur until the rickety period has gone by. Yet it 
is called rickets. Sir W. Jenner says : " I have seen rickets 
begin in children seven and eight years old." There is much 
difficulty in coming to a definite conclusion on such a point, 
for, on the one hand, there is no improbability in the occur- 
rence of a true rachitic condition at this time of life, seeing 
that the skeleton is still in an active state of development 
and growth — on the other, it is equally admissible to hold 
that some such condition of resorption of mineral matters 
and degeneration takes place as appears to happen in 
mollities. 



370 DISEASES OF CHILDREN. 

Symptoms. — These children are born healthy, and in 
some cases at least, they have come of perfectly healthy 
stock. The recorded cases show that up to a certain period 
they have been strong, and then, perhaps after some serious 
illness such as measles or scarlatina, in an insidious way, 
generally with more or less pain, the extremities have 
become bent. In more than one instance fracture has oc- 
curred in one or more of the bones. Then the thorax has 
flattened in, and thus the case has remained, sometimes for 
many years, with stunted growth, and sometimes also with 
childish intellect. In a few instances death occurs, perhaps 
from bronchitis or some other thoracic affection. 

Morbid Anatomy. — Very few data exist on this head. 
Such as there are, show that in the majority of these 
cases the bones are exceedingly thin and brittle. This is 
seen (a) from the frequency with which fractures have oc- 
curred, sometimes in several bones, from very insufficient 
causes ; and (b) from observations such as that of Mr. Bar- 
well, who records that he operated upon one of these cases 
to remedy a deformity, and the chisel went through the bone 
with the greatest ease ; while, on passing his finger into the 
wound, the bone was a mere thin shell, full of an excess of 
oil. 

Another case is on record,* in a boy of eleven, who 
was subjected to examination by Dr. Hilton Fagge, Mr. 
Warrington Haward, and Dr. Drewett. These gentlemen 
considered the change to be identical with those of rickets. 
The wrist ends in this case were enlarged, the bones were 
much distorted, and the child was quite helpless. He sub- 
sequently died, and a post-mortem examination was made 
by Dr. Abercrombie and Dr. Barlow, and the epiphysial 

* A Case of Late Rickets, by Dr. Dawtrey Drewett : " Trans. Path. Sue , 
Lond.," vol, xxxil, p. 386, 



RICKETS. 371 

line of the bones was found thickened and irregular, as in 
common rickets. 

There is yet another case worth mention, in a girl of 
ten, under the care of Mr. Davies Colley.* She had always 
been pale, thin, and delicate,' and from an early age the 
ankles grew outward and the knees inward. The humerus 
fractured, and subsequently the femur, and for this, at the 
age of ten, she first came to Guy's Hospital. It was then 
found that the long bones were very tender and flexible, 
and that their outer shell could be pressed inward like the 
skull in craniotabes. The urine was very deficient in phos- 
phoric acid, only one-third the normal amount being pre- 
sent : the calcium was in excess. She died, at the age of 
thirteen, from a suppurative pyelitis, due to the formation 
of phosphatic calculi. After death several of the bones 
were found much distorted — some were hypertrophied and 
dense, others light and thin, and, in some, were tumorous- 
looking expansions of a light porous bone, with fibrous- 
looking tissue intersecting them. The microscopical exami- 
nation by Mr. Symonds showed a complete absence of 
compact tissue and of Haversian systems, a porous bone 
being filled by fibrous tissue. Mr. Symonds remarks that 
this development of fibrous tissue with great wasting of 
the bone agrees with the description of late rickets, as 
described by Cornil and Ranvier, rather than with osteo- 
malacia. But if it agrees with late rickets, it can hardly be 
said to do so with common rickets ; and the author stated 
the case of late rickets in a threefold manner in order to 
show that, whether or not all these cases are related to 
each other, there are at any rate several kinds of disease 
included under this term — some "identical with rickets;" 
some evidenced by atrophy and fragility of bone, very like 

*" Trans. Path. Soc, Lond.," vol. xxxv. 



372 DISEASES OF CHILDREN. 

osteo-malacia ; some not quite like either, possessing in 
addition peculiar features, which make them difficult to 
classify. 

Besides cases such as have now been mentioned, Rehn, 
of Frankfort, has described a condition, which he calls "In- 
fantile Osteo-Malacia" which differs in some points from 
ordinary rickets. The bones of the skeleton become thin, 
soft, and porous, and their medullary canals disappear before 
an advancing growth of soft porous bone. The bones so 
affected are quite readily cut with a knife ; but in the only 
two that were examined after death, there were distinct 
rachitic changes in the cartilage zone, though but moderate 
in degree. 

This state of things occurs in young children. A case 
of the same nature occurred to Dr. Goodhart in a girl 
fifteen months old. In the skull, the new growth and con- 
sequent thickening was enormous ; a pile-like new bone 
gradually monopolized the diploic space ; in the extremi- 
ties, fusiform nodes were produced, in which more or less 
of the entire thickness of the shaft was converted into the 
same soft material. These alterations were associated with 
pronounced rachitic changes in the ends of the bones, and 
some have considered the entire process a rachitic one ; but 
the marked degree of generalized bone-softening, and the 
enormous development of imperfect bone, are conditions 
which form no part of common rickets in the human sub- 
ject. Bone changes, in many respects resembling these, have 
been found in unquestionably syphilitic infants. " But," 
borrowing the words of the committee that examined the 
specimens,* "that such are necessarily and solely syphilitic 
appears to us in our present state of knowledge not proven. 



* Dr. Hilton Fagge, Dr. Barlow, Mr. Warrington Haward, and myself : 
Trans. Path. Soc, Lond.," vol. xxxiv, p. 201. 



RICKETS. 373 

The apportionment of the effects produced severally by 
rickets and syphilis in this and other cases cannot as yet 
be determined." Very much the same must be said of late 
rickets and its relation to osteo-malacia. Some cases more 
resemble rickets, others osteo-malacia ; but whether the 
real meaning of this be that the two diseases are the same, 
with now one part of the process now another in the as- 
cendant; or whether we have several distinct diseases which 
in anatomical change resemble each other, is uncertain in 
our present state of knowledge. Let the obscurity that 
surrounds the subject stimulate the reader to investigate 
these very interesting diseases. It should be added that 
Dr. Judson Bury, of Manchester, has recorded a case of a 
female infant of eight months,* which, in the absence of 
any rachitic changes in the appearances in the medulla, in 
the thinning and easy fracture of the bones, is not unlikely 
to have been an example of true osteo-malacia. Dr. Thomas 
Barlow has exhibited specimens of bones from this case, 
and the appearances closely resemble those of the osteo- 
malacia of adults, whilst those of rickets are absent. 

Prognosis. — This must be somewhat guarded. Fractures 
in these cases repair readily, so that there is no want of 
activity "of a sort, although it is hardly of the kind that is 
required. Some of these cases have lived sufficiently long 
to pass out of notice, a few have died from bronchitic and 
other complications. 

Treatment. — They must be treated on the same lines as 
the rachitic patient, and it will be unnecessary to say more. 
Inasmuch as the bones fracture spontaneously with the least 
force, the greatest care must be taken to avoid all undue 
movement and exertion. 



*" A Case of Osteo- Malaria in a Child: " British Medical Journal, 1884, 
vol. I, p. 213. 
. 32 



374 DISEASES OF CHILDREN. 

Foetal Rickets. — The occurrence of true rickets at birth, 
or congenital rickets, is very rare. Most authorities doubt 
whether it ever. occurs, although one need not be surprised 
at the occasional occurrence of such a condition. Steiner 
mentions the existence of a specimen of rickety foetus in 
the museum of the Hospital for Sick Children in Prague, 
and other cases are on record; but none are free from 
doubt, owing to the fact that foetal rickets, which has not 
till lately been distinguished, is probably not rickets. 

In the foetal disease neither the bone nor cartilage lesions 
are those of rickets, but they are those of cretinism. Mr. 
Shattock, however, considers that some of the cases illus- 
trate a condition of rickets which has begun and ended in 
ntero. The characteristics of foetal rickets are : the facial 
appearance — the small forehead ; thick lips ; flat nose and 
pallor ; the flat, spade-like hand ; the extremely stunted 
bones, the latter on section showing relatively large carti- 
laginous epiphyses, and the absence of any irregularity of 
cartilage next the bone, or, indeed, of any kind of rachitic 
change in the cartilage. 

3. Rheumatism. — " The fundamental difficulty in dis- 
cussing rheumatism consists in defining what we mean by 
it," writes Dr. Thomas Barlow, and, true as this is as regards 
adults, it is still more true of children, who comparatively 
seldom suffer from acute rheumatism in such a pronounced 
form as is met with in older people. Children, indeed, 
suffer from typical acute rheumatism, with its fever, its pain, 
its swelling of the joints, its sweating; but to circumscribe 
it by these limits only, would be to ignore the larger part 
of the field of its workings, and to form a most inadequate 
conception of what rheumatism is capable of doing in child- 
hood. 

Acute rheumatism in the adult we all know well. It is a 
disease which sends the patient to his bed for weeks at 



RHEUMATISM. 375 

times; which is attended with fever; with profuse sour 
sweating and miliaria ; with swelling and redness of the 
larger joints of metastatic development ; with much pain, 
and with, in many cases, acute peri- or endo-carditis and 
pleurisy, or pneumonia. 

The disease is found in children in like manner ; the 
older the child, the more likely is it to be typical ; but a 
classical attack of acute rheumatism may be found at any 
age. The author has seen it as early as two years, and 
more doubtful cases even in children of two and three 
months only. 

Speaking generally, children's rheumatism is wanting in 
the severity of any one symptom, and its existence is often 
revealed by no more than one of many. There is but little 
fever — but, stay, we must hardly say that, for it is a common 
thing in young children to have a temperature of ioi°, or 
so, which, if not tested, would have passed for nothing for 
all the history that the doctor could obtain. It is probable, 
however, that the temperature is not often abnormally high 
for more than a day or two. The profuse sour-smelling 
perspiration so common in adults is almost absent in 
children. Of sweating there is but little, and of acidity of 
smell, none. The pain is less severe, and though the 
patients fret, they drag about. The joint affection is less 
severe, the swelling has to be searched for, and often it 
happens that the puffiness of one ankle, or wrist, or knee, 
associated with pain, when pointed out to parents, has been 
recognized, but thought unimportant. Supposing the illness 
is sufficient to keep the child in bed, it may still happen that 
only one joint is affected, and that with the slightest swell- 
ing and the faintest blush. 

There can be no doubt that a large number of children 
suffer from rheumatism in this way, and never go to bed at 
all ; others, perhaps, who are kept in bed for a day or two 



376 DISEASES OF CHILDREN. 

yet never see a doctor ; and in either case, when, years 
afterward, some old valvular mischief needs explanation, 
there is no memory of the preexistence of any disease. 

But what is true of these symptoms is not true of the 
heart. It is an old and thoroughly acknowledged maxim 
that in rheumatism the younger the patient the more the 
risk of heart disease ; but more than this, since the tout en- 
semble of adult rheumatism fails in children, and this part or 
that is affected solely, so is it with the serous membranes of 
the thorax as well as with those of the joints. And though 
such cases are not common, an acute pericarditis or an acute 
pleurisy is sometimes the first and only evidence of rheu- 
matism. 

It is highly probable that an acute endocarditis may, in 
like manner, be the sole index of the rheumatic state. One 
might say that it certainly is so, but that from the nature of 
the evidence demonstration is less easy, and unless one has 
watched the onset of the murmur, it is often impossible to 
say what is its age. 

From this description it will be apparent that the rheuma- 
tism in children is apt to be expressed by very indefinite 
symptoms. If a child is suffering from acute pleurisy, for 
example, what is there in it which will warrant one calling 
it rheumatic ? Probably nothing. The significance of inde- 
terminate symptoms as indicating rheumatism has been 
shown by a careful study of life histories, and it is by this 
study in individual cases that a particular symptom will 
have to be judged. Acute rheumatism, therefore, is not 
common. It is represented in childhood by what are called 
growing pains, by a little transient swelling of one joint, by 
pleurisy, by pericarditis, by a progressive or persistent 
anaemia, which leads to a medical examination, then valvu- 
lar disease may be detected. The disease is only to be 
correctly apprised by the most careful inquiries into the 



RHEUMATISM. 377 

family history and the small ailments from which the child 
has previously suffered. 

It has been said that it is more common in girls than in 
boys, and in sixty-nine cases passing under the notice 
of Dr. Goodhart, forty-two were in girls, twenty-seven in 
boys. The attack appears most commonly as a general 
one — that is, localized to no one joint, and oftener by far in 
no joint at all, but being associated with general pain or 
soreness all over. Again, taking the same series, there are 
twenty-six thus generalized ; fourteen others in which the 
knees were chiefly at fault; fourteen where the ankles were 
swollen ; three only in which the wrists were alone affected. 
There are other complaints which ought to be mentioned. 
Thus, four cases complained only of extreme pain in the side, 
which, in the absence of local inflammations of pleura or 
pericardium, must be attributed to a rheumatic muscular 
condition. The neck was alone affected once, the pericar- 
dium alone once. There is no note of anything that could 
have been called meningitis. At the same time the author 
has occasionally seen cases of meningitis in children with 
rheumatic family histories, which have raised, though unfor- 
tunately not solved, the question of a rheumatic meningitis. 
The fever has generally been of the most moderate, or at 
any rate has easily been controlled by drugs. In the last 
ten cases taken from Dr. Goodhart's note- books, which are a 
very fair sample of the usual run of such cases, the long- 
est duration of any rheumatic symptoms was four days, 
except in two cases, where bad peri- and endocarditis com- 
plicated the disease. Contrary to the opinion of some, the 
author thinks that relapses are uncommon ; but again he 
adds that this statement is based upon cases treated almost 
invariably by salicylic acid or its compounds. 

In making this statement he refers to such recurrences of 
the disease as have some definite time-relation to the pri- 



378 DISEASES OF CHILDREN. 

mary attack — that is to say, which occur within a few days 
or a week or two of each other ; and he also excludes 
what might perhaps be considered of the • nature of a 
relapse, the onset of chorea as the rheumatism subsides. 
Children, like adults, once they have had rheumatism, are 
liable to recurrent attacks of pain of no great severity. As 
already stated, these are by no means to be made light of, 
since they possess a well-known tendency to associate 
themselves with lesions of the heart and its valves ; but 
they are to be looked upon as of the nature of fresh attacks, 
or of the persistence of a status rheumaticus rather than as 
the recrudescence of a worn-out malady. 

As in adults, but more commonly than in them, acute 
pericarditis and endocarditis (the latter far more frequently) 
are often associates of acute rheumatism. But for the reason 
already given, that the rheumatism so] often escapes notice, 
it is almost impossible to say what proportion of cases occur 
as the direct outcome of the one attack, or how far it re- 
sults from some persistent state which slowly and surely 
damages the valves. Of the series of sixty-nine cases of 
acute rheumatism, fifteen had organic disease, one aortic 
disease, two pericarditis, and the remainder mitral disease ; 
and five more had sufficiently pronounced symptoms of 
cardiac disturbance, such as alteration in quality of the 
sounds, displacement of impulse, irregularity of action, as 
to make it probable that there -was also actual disease. 

Acute rheumatism is strongly hereditary. Of the same 
sixty-nine cases, thirty-two had a good history of rheuma- 
tism in close relatives, father, mother, or brothers, or sisters ; 
nine more had a moderate rheumatic strain, the disease 
having occurred in uncles, aunts, or grandparents ; in four 
the history was vague ; seventeen had no ascertainable 
rheumatic taint ; and no statement was made upon the point 
in seven. The remarkable power of transmission which 



RHEUMATISM. 379 

rheumatism occasionally shows is well illustrated by a case 
Dr. Goodhart published in the " Guy's Hospital Reports," 
vol. xxv, where, with a rheumatic strain both in father and 
mother, five out of a family of six children under fifteen, 
all but a baby of fourteen months, had either had rheuma- 
tism or heart disease. A boy of fifteen had had rheumatic 
fever twice, and had mitral regurgitation ; a second boy, 
aged ten, was similarly affected ; the third, a girl, aged eight, 
died of mitral disease ; the fourth, a girl, had rheumatic 
fever (after scarlatina), with subsequent progressive thicken- 
ing of the mitral valve ; and the fifth, a boy, aged four, was 
laid by all one winter, with rheumatism. Steiner gives a 
yet more striking case, where a rheumatic mother had 
twelve children, and eleven of them had had rheumatism 
before the age of twenty. 

The larger part, however, of the rheumatism of childhood 
consists of isolated, and, at first sight, disconnected, ailments, 
which must now be enumerated seriatim. 

Tonsillitis may be mentioned first, because there is a grow- 
ing frequency of assertion that it is a rheumatic ailment, 
generally as preceding the attack. It is probably more com- 
mon in adults and adolescents than in children. The author 
has notes of only a few cases of the kind, but it is an ail- 
ment which no doubt often passes unrecognized. 

Next we may take chorea. This, as one of the most 
prominent of the diseases of childhood, will receive con- 
sideration on its own merits in the appropriate chapter ; but 
in relation to rheumatism it is important to bear in mind 
that it not uncommonly precedes, more often it succeeds, 
and occasionally it alternates, so to speak, with rheumatism. 
Cases occur where chorea is followed, and, in great measure, 
replaced, by acute rheumatism, and, as the latter subsides, 
the chorea comes back again. 

Heart disease is another symptom of rheumatism. It hap- 



38O DISEASES OF CHILDREN. 

pens over and over again that a pale and emaciated child is 
brought for treatment. Mitral disease is detected, and yet 
there is no history of previous rheumatism. Inquiry reveals 
that one or other of the parents has had rheumatic fever, 
perhaps, also, some one or other of the brothers or sisters. 
We are fairly justified in regarding such cases — always sup- 
posing that the rheumatic attack has not been overlooked 
— as cases where the rheumatism has localized itself in a 
particular part. In a few cases one sees even young infants 
with heart disease, which, had it not been that there was a 
rheumatic family history, would have been supposed, with- 
out question, to be due to malformation. Pericarditis, in 
like manner, may be the primary disease, and the joint affec- 
tion develop later, or not at all. As illustrations of these 
points, the author mentions the following cases : — 

An infant, aged two and a half months, ailing for four 
weeks. It was extremely pallid, with a cantering action of 
the heart, and a loud systolic mitral bruit audible all over 
the prsecordia, and in the axilla and back. Its mother had 
suffered from what was probably rheumatic fever when 
twelve or thirteen years of age. 

A boy of fourteen, with pains all over him, and extreme 
anaemia, was admitted for irregularity of the heart, and de- 
veloped an acute pericarditis without any definite rheumatic 
attack. 

Another boy, about twelve, was admitted for pericarditis, 
and developed a rheumatic affection of the joints some three 
or four days later. 

A girl, aged eight, with a rheumatic father, and who had 
suffered nine months before with rheumatic fever, was ad- 
mitted with left pleuro-pneumonia, followed within a few 
hours by pericarditis. She was in the hospital seventeen 
days, and had no joint trouble at any time. 
• Acute pleurisy and pleuro-pneumonia are sometimes the 



RHEUMATISM. 38 1 

symptoms of rheumatism. They are very commonly part 
of acute rheumatism ; but allusion is now made to the fact 
that just as a pericarditis may be the only indication of 
rheumatism, so also may pleurisy or plcuro-pneumonia. 
The case just mentioned is an illustration of this. 

As other features of a rheumatic attack may be mentioned, 
first of all, certain acute erythematous affections of the skin. 
Urticaria is one of these ; and for the rest, perhaps, erythema 
multiforme is the best general term, for the eruption is some- 
what diverse in appearance — now papular, now marginate, 
and occasionally associated with purpura. Next, there are 
the subcutaneous nodules, which have been described by 
Barlow and Warner. These are small inconspicuous 
masses, which occur mainly about joints. The back of the 
elbow, the malleoli, and the margins of the patellae arc the 
commonest sites ; but search should also be made along the 
vertebral spines, the crista ilii, the clavicle, the extensor ten- 
dons of foot and hand, the pinna of the ear, the temporal 
ridge, the superior curved line of the occiput, and the fore- 
head. They may be solitary or in crops, are painless, and 
generally more palpable than visible. They appear and dis- 
appear in a few weeks, sometimes in a few days, and in rare 
cases persist for many months. They are fibrous, nucleated 
in structure, and some are possessed of considerable vascu- 
larity. These nodules are of considerable importance in 
two respects. In the first place, inasmuch as they un- 
doubtedly occur in the course of, or as a sequel to, acute 
rheumatism, they may be of considerable use in establish- 
ing a diagnosis in doubtful cases ; and, in the next place, it 
has been shown by Drs. Barlow and Warner that they are 
almost invariably associated with disease of the heart, and 
more often than not with a progressive form of disease. 

There yet remain to be mentioned some few lesser 
ailments, which, while they do not appear to have any 



382 DISEASES OF CHILDREN. 

constant or even frequent relation with rheumatic fever, 
are nevertheless found in particular children, and suffi- 
ciently often, in those who have a rheumatic family his- 
tory, to justify their inclusion in the composite of rheu- 
matism. 

Children of rheumatic parentage are often habitually 
anaemic and thin. As a matter of practice, if one has to do 
with a child who is anaemic, thin, and of dark aspect, with- 
out any particular transparency or delicacy of skin, it is 
best always to inquire very carefully into the family history, 
and rheumatism probably taints more than an average of 
such. The rheumatic diathesis is said by some to be ex- 
pressed by a fair complexion. Our own experience leads to 
the opinion that a dark complexion is more prevalent. 
This, however, is a question which depends so much upon 
what individuals consider to be evidence of rheumatism, 
that it is not necessary to attempt to upset the generally 
received statement. 

Nervousness is not a scientific term, perhaps, but it is one 
in common use with parents, and expresses a variety of 
conditions which are important to note. Of these, a sub- 
choreic condition is one. A child is constantly fidgeting, 
or making grimaces, or performing irregular movements of 
his fingers or hands, or he is clumsy in his movements. 
Another has an irritable or exhausted nervous system after 
what to healthy children is moderate play. The nervous 
child becomes unusually excited while playing, perhaps 
suddenly bursts into a cry, or becomes ill-tempered without 
cause, or, after the game is over, quite tired out, and want- 
ing to lie down ; or maybe he is actually languid and ill for 
some days afterward. Sleep comes to such badly if they 
play toward their bedtime, and they wake up fitfully, talk- 
ing or screaming. 

Nightmare is another rheumatic associate. It is very 



RHEUMATISM. 383 

common — seventeen out of a series of thirty-seven owned 
a rheumatic parentage. 

Obstinate headache in children is frequently found in rheu- 
matic families. It is prone to be associated with the anaemia 
of which mention has already been made. Of thirty-three 
cases of headache, twenty-three were of rheumatic stock, 
five of epileptic, and five only, showed no abnormal taint. 

Stiff neck is another ailment quite common in childhood, 
and for which, perhaps, lumbago is substituted in the adult. 
Whether this be so or not, however, it is best to teach that 
stiff neck, an ailment of childhood, and lumbago, one almost 
confined to adult life, are both diseases of the rheumatic 
strain. Barlow suggests that the isolated phenomena met 
with in the rheumatic, and of which stiff neck is one, are 
the acute rheumatism of the adult distributed, so to speak, 
and it may be so ; but it cannot be said that this condition 
is observed in those who have actually suffered from joint 
troubles or heart disease at any former period. Among 
other troubles which may be said to be of this sort, there 
are spasm of other muscles, causing sometimes retraction 
of the head, the peculiar inturning of the thumb upon the 
palm, and the toes to the sole of the foot, which is called 
tetany ; also muscular tremors of various kinds, stammer- 
ing, and nocturnal incontinence of urine — all these things re- 
duced to their cause, or to come as near to it as may be, are 
nerve discharges, excited by morbidly slight stimulation or 
irregularity in the discharging act. And there is another 
feature of the rheumatic child which is no doubt allied to 
these — viz., a frequent stomach-ache soon after the ingestion 
of food. A number of such children tell a tale of pain dur- 
ing or soon after a meal, and this is often associated with an 
action of the bowels. Their food is said by mother or nurse 
to run through them. Now what happens is surely this, 
that the nervous supply to stomach and intestine is morbidly 



384 DISEASES OF CHILDREN. 

irritable and responds to the introduction of fresh food by 
excessive vermicular action. It may be added, as part of 
the argument, that a little opium in the form of Dover's 
powder almost certainly cures the complaint ; and on simi- 
lar lines, Dr. Marshall prescribes salicylate of lithia, he 
thinks, with great advantage. 

Of skin diseases, psoriasis and erythema nodosum occur 
in the rheumatic, and the latter in a peculiarly marked man- 
ner; for of twenty-nine cases, nineteen were rheumatic, five 
only were certainly not so, five had not been interrogated 
upon the point. Allied to this affection is the purpura that 
occurs in the rheumatic, or the more definite peliosis rheu- 
matica which occurs in the form of crops of purpuric, ting- 
ling papules. But this is more common in adults than in 
children. 

Diagnosis. — There is less danger of rheumatism being 
mistaken than of its being overlooked ; but the author has 
several times seen a rheumatic hip give rise, by the per- 
sistence of pain and absence of swelling, to the suspicion of 
early disease of the joint ; and there are other affections of 
the bones and joints which sometimes lead to mistake. 
There is an occasional acute suppurative disease of hip or 
knee in infants ; there is the acute inflammation at the epi- 
physial lines which takes place in infants with congenital 
syphilis ; there is the hemorrhagic periostitis which occurs 
in scurvy ; there is acute ostitis and necrosis with pyaemia 
— that fatal disease which is so common in childhood and 
which is constantly mistaken at first for rheumatic fever; 
there are the effusions into the joints which take place in 
bleeders (haemophilia) ; there is the pain and tenderness of 
rickets ; — all these, by the pain and immobility which they 
occasion in young children, may be thought to be rheu- 
matic without much difficulty, if we are not on the lookout 
to discriminate between them. And again, as Barlow has 



RHEUMATISM. 385 

pointed out, there is much in the early stages of infantile 
paralysis to liken it to acute rheumatism. There is often 
fever and general tenderness in the affected limbs ; and 
Barlow records a case of a child in whom, for more than a 
fortnight, there was extreme tenderness and a little redness 
and swelling of the dorsum of each foot. 

Having said this much, however, it may also be suggested 
that the rheumatic state may act upon different individuals 
in different ways, and thus may produce, in some, effects 
which we are wont to attribute to other causes. This point 
may be illustrated by infantile paralysis. This is a disease 
which suddenly attacks healthy children with fever, and 
which end in paralysis. We know absolutely nothing of 
the disease, except that it produces certain results. To any 
one who should affirm that infantile paralysis is due to the 
rheumatic poison we could say nothing, as we have no evi- 
dence for or against such an opinion, and clearly there is no 
reason why it should not take its place as one of perhaps 
a number of possibilities, however unlikely or small its 
chance, so to speak, may be. But the point of this is 
equally true as regards joint disease and serous inflamma- 
tions in the rheumatic. We generally assume, in dealing 
with any destructive joint disease, that it is not rheumatic, 
because it is a generally accepted maxim that rheumatic 
inflammations are prone to resolve. But if, as soon as we 
see a chronic synovitis or destruction of a joint resulting 
from it, we at once exclude rheumatism because of the con- 
dition, what chance have we of ever ascertaining the natural 
history of the disease ? Dr. Goodhart believes that per- 
manent disease in various parts is no uncommon result of an 
attack of rheumatism which has been overlooked. We 
allow this much without question as conclusively estab- 
lished in the case of the heart, but for pleura or joint no 
such teaching is accepted. It would be well to make a 



386 DISEASES OF CHILDREN. 

revision of statements on this point, based upon a careful 
inquiry into the life history of the individual, his family his- 
tory and antecedents, in all such children as are affected 
with chronic joint disease and empyema. Of course, such 
common affections are due to a great variety of causes, 
many of them in no way rheumatic, but it cannot be 
doubted that rheumatic inflammation adds its quota to the 
total. 

Of scarlatinal rheumatism enough has been said already. 
If it be a distinct disease, the counterfeit is at any rate so 
like the original as to be undistinguishable. There is the 
same metastatic affection of joints, the same tendency to 
the occurrence of an endocardial murmur, the same relief 
by the salicylic acid treatment. It differs in one or 'two 
points, perhaps, if the type of disease be drawn from a large 
number of cases, for there is but little tendency to peri- 
carditis ; the endocardial murmur is prone to disappear — 
though this must not be taken to indicate that the bruit has 
been of a " functional " nature, and unassociated with endo- 
carditis — and there is some, though but slight, tendency to 
the occurrence of acute suppuration in the joints. These, 
however, do not constitute any essential differences, and the 
disease may be regarded as probably acute rheumatism. 
One may be the more inclined to do this, as cases are apt to 
occur in rheumatic families, and it is therefore likely that 
it is a constitutional trait, which develops itself under the 
altered condition of health produced by the scarlatina. 

Dr. Ashley distinguishes between true rheumatism and 
another joint affection which complicates scarlatina more 
commonly than it. It is, he says, not often associated with 
endocarditis, but a dry pericarditis of short duration, and 
unattended with obvious symptoms, is commoner than is 
supposed. The attacks are more fugitive ; they rarely recur 
in joints when once they have left them ; and they exhibit 



RHEUMATISM. 387 

a favoritism for the backs and palms of the hands, the 
finger joints, the soles of the feet, and the cervical verte- 
brae. It mostly occurs from the seventh to the ninth day 
of the fever, and in cases where the pyrexia from the fau- 
cial inflammation is longer than usual. It is commoner in 
some epidemics than in others. True rheumatism, on the 
other hand, is more liable to recur in the third or fourth 
week — much at the time that nephritis supervenes, and 
endocarditis is by no means uncommon. 

Rheumatism has no morbid anatomy, save such as at- 
taches to the heart, and to this belong no peculiarities. In 
the acute stage a little lymph may be found in the joints, 
and in any severe case there may be acute pleurisy, some- 
times peritonitis, or acute pneumonia in association with 
acute pericarditis. But it may be said, in short, that acute 
rheumatism is fatal by its pulmonary and cardiac complica- 
tions ; and that, when it is so, it is usual to find acute peri- 
carditis and endocarditis, the muscular wall of the heart 
being pale, softened, and dilated ; the weight of the heart is 
increased, and usually very much so, probably in great 
measure by acute inflammatory swelling, and the lungs are 
in that peculiar condensed, solid, sodden condition of leaden 
color, which has usually been called cedematous. This 
condition is commonly double-sided, and is associated with 
more or less pleural effusion. 

'Treatment. — The treatment of acute rheumatism follows 
the same lines as the disease in adults. The child must be 
kept in bed, between blankets or well covered in flannel, 
and any painful joints are to be swathed in cotton wool. 
The diet strictly farinaceous ; milk and bread and butter, 
biscuit, etc., may be allowed. Since Dr. Maclagan first 
recommended salicin, all our cases have been treated either 
by it or salicylate of sodium, the latter far more often, on 
account of its cheapness. By its means the attack, if free 



388 DISEASES OF CHILDREN. 

from complications, has been a disease of comparative un- 
importance, and relapses have been almost unknown. Eight, 
ten, or fifteen grains may be given every three hours ; ten 
grains is the usual dose for a child of eight or ten, and it is 
given with syrup acetate of ammonium ; this usually for 
three or four days, when it is reduced to three times a day, 
and then, after a week or so, combined with quinine. 
Should there be any pericarditis or acute endocarditis, the 
chest is to be covered with wool, or spongio-piline, or poul- 
tices, and small doses of opium, in the form of Dover's 
powder, given three or four times in the twenty-four hours. 
Three or four grains of the powder may be given to a child 
of six or eight, and belladonna or digitalis must be given 
if necessary, according to circumstances. The salicylates 
are supposed to be inclined to disturb the heart's action, 
and are therefore sometimes discontinued when heart dis- 
ease sets in ; it has also been stated that, after its onset, 
their continuance is unattended with good effects upon the 
rheumatism. It must always be given with caution and 
careful supervision in such cases, but it is not necessary to 
withhold it, unless there should be distinct indications for 
doing so. But there is this to be said, that when the heart 
attack is severe, the joint affection is very slight, or none at all. 
The cardio-pulmonary condition, described above, is a 
most puzzling one to treat. The child lies propped up in 
bed, extremely pale, with dilating alae nasi and rapid breath- 
ing, the heart pumping away at 120 to 160 beats per 
minute ; there is acute pericarditis and mitral disease also, 
though this is often uncertain from the confusion of sound 
produced by the pericarditis and the rapid action. The 
chest shows considerable dullness and high-pitched tubular 
breathing, probably from the seventh or eighth rib down- 
ward, at both bases. In such cases it is very difficult to 
say what drugs do good, and whether a case is to do well 



RHEUMATISM. 389 

or badly. Undoubtedly the most essential requisites are 
careful nursing and judicious feeding; these, and opium 
given internally, will steer many cases through the peri- 
carditis — the heart's action quieting down, and the pleuritic 
effusion and solidification of the lung slowly clearing up. 
But there are, unfortunately, many cases, not differing much 
in the physical conditions ascertainable, in which the child 
becomes more restless, vomiting supervenes (one of the 
worst symptoms possible in cases of this kind), and the 
child dies quite quickly. These are cases in which brandy 
must be administered freely. Ether is, no doubt, a useful 
drug under these circumstances, but it is not one that chil- 
dren take readily, and it is often vomited, in which case, 
however, it may be injected subcutaneously. 

Regarding the treatment of the rheumatic child — whether 
it be rheumatic by any attack of former acute rheumatism, 
or its tendencies shown by some of the lesser ailments in- 
cluded in rheumatism and associated with hereditary taint — 
there is much to be said. Such children require the most 
watchful medical care, and much more than is usually con- 
sidered necessary by their parents — uninstructed, as most of 
them are, as to the meaning of trivial ailments in such chil- 
dren. A tonsillitis, a headache, paleness, etc., do not neces- 
sarily suggest the advisability of an examination of the 
heart ; but such conditions in these children are to be 
looked upon as part of the life-history of rheumatism, and 
unless the heart be examined — or supervised — disease may 
be creeping on where we least expect it. These are some 
of the cases where the doctor should be remunerated for 
keeping the child welly rather than called in to cure it when 
actually ill. His fee should be an annual retainer, irre- 
spective of any illness, and there is no doubt that rheuma- 
tism and its results would be diminished. The manage- 
ment of the rheumatic child requires discretion at all points. 
33 



390 DISEASES OF CHILDREN. 

It is not only that its diet and its clothing require it, educa- 
tion and play alike call for advice in many instances, and 
the question of residence, although often quite beyond 
power of alteration, is one of vital importance. Of course, 
until we know what rheumatism is, we must deal to some 
extent in generalities, which may be open to discussion ; 
but with this admission, it may be said that warm flannel 
clothing is essential ; the diet should be varied, and con- 
tain plenty of easily digested vegetables, in addition to 
the milk and ordinary food ; and both as regards work and 
play, the slightest indications of excess, in the way of 
exhaustion — whether this be temporary or continuous, 
any headache, tendency to nightmare, or what has been 
called nervousness — must lead to immediate moderation. 
For such children the greatest care should be exercised in 
the selection of a school, both as to a dry, warm climate, 
the home life therein, and the happiness of the child ; and 
unless all these things are satisfactory, it is far safer to keep 
the child at home. 

The rheumatic child is one who requires drugs on occa- 
sion. Whenever it is below par, or getting anaemic, some 
good tonic should be administered, such as compound 
syrup of the hypophosphites, with this may be combined 
arsenic, as one of the most useful of remedies for cases of 
this sort. Five drops of Fowler's solution, or seven, or 
ten, with half a teaspoonful of the syrup, taken continu- 
ously for a month or six weeks, is a most valuable help 
in these cases, and cod-liver oil, stout, maltine, and such 
things, are also to be recommended. 

For the nervous or excitable condition, particularly in 
girls, the bromide of ammonium, bromide of potassium, 
hydrobromic acid, and manganese are of value ; and for 
the nightmare which occurs in younger children, bromide 
of potassium and hydrate of chloral combined, form almost 



RHEUMATIC GOUT. 39 I 

a specific. Five grains of the bromide and one or two 
grains of chloral (half-drachm of the syrup), may be given 
to a child two years old, and continued as a draught at 
bedtime for a few days, with the almost certainty of suc- 
cess, care being at the same time exercised that the excite- 
ment of the day be reduced to its minimum. Such chil- 
dren require attention to the bowels, which are liable to be 
irregular. If so, some gentle aperient in the shape of 
fluid magnesia, effervescing citrate, licorice powder, syrup 
of senna, confection of senna, or the fluid extract of cas- 
cara sagrada, in doses of ten to thirty minims, may be 
given, and a little tincture of nux vomica also is sometimes 
of advantage. The treatment of nocturnal incontinence is 
discussed under the head of " Genito-urinary Diseases." 

Ostco-artJ iritis, or Rheumatic Gout, occurs in children occa- 
sionally. Dr. Goodhart has seen at least five well-marked 
examples, two in boys and two in girls, and one in whom his 
memory fails as regards sex — from twelve to sixteen years 
of age. Four were severe cases — that it to say, attended 
by considerable bulky swelling of many joints, large and 
small (fingers, wrist, knees and ankle) ; three of them had 
moderate but persistent fever, all were anaemic. One, a 
girl, died of phthisis after a long illness. One, watched by 
Mr. Sutton Sams, practically got well on iron in full doses. 
The others were habitual cases, and they passed out of 
sight unimproved. 



PART IV. 
THE DIATHETIC DISEASES. 



i. Acute Tuberculosis. — Acute tuberculosis must of 
necessity be several times touched upon in connection with 
the different viscera which the disease more particularly 
affects ; nevertheless, it is such a distinct disease, and has 
so definite a clinical position, that a few words may be 
devoted to its more general bearings. It is a disease con- 
fined to no age, but is particularly one of childhood. 

Pathology. — But little is known of its nature at present, 
although of late years several very interesting observations 
have been made, which, if they ultimately take rank as as- 
sured facts, are of the greatest importance. First of these 
may be mentioned the discovery of the bacillus tubercu- 
losis. This small body is supposed to be the virus which, 
introduced from without, forms a nidus in some of the lym- 
phatic structures, provokes caseation, and thence, by fertiliz- 
ing, becomes disseminated in all parts of the body. Certain 
experiments, too, have of late been carried out, which go to 
show that tubercle is propagated by inoculation only when 
the bacillus forms part of the virus which is introduced, in 
contradiction to previous less rigid experiments, which 
pointed to the probability of any suppurative focus being 
sufficient for the purpose. Next, there is a disease well 

known among; cattle, which, having; much of the anatomi- 
es >> o 

cal distribution and histological structure of tubercle, is 

393 



394 DISEASES OF CHILDREN. 

capable of transmission from the diseased animal to the 
healthy by means of the milk from diseased cows. Other 
observations are accumulating, which go to show that, pos- 
sibly under favoring circumstances, tubercular diseases may 
be transmitted from man to man ; and, lastly, we have the 
features of the disease itself, which are, in many respects, 
those of a specific fever. The subject is hardly one for dis- 
cussion here, it is so much a question of general pathology. 
Without indicating a leaning in either direction, this much 
may be said. Hereditary tendency, the infrequency of any 
proved contagion, the history of the disease as we see it 
going slowly on over ten, fifteen, twenty years in the lungs 
of adults — not to mention the doubt which must long weigh 
heavily against establishing such an important position for 
such minute organisms as these — must make any one hesi- 
tate to accept the doctrines of tubercle as at present stated ; 
none the less, they are well worth consideration when we 
think over a disease so obscure as is acute tuberculosis. 

It is supposed, however, by many who adopt the infective 
theory in its entirety, that whenever acute tuberculosis 
occurs there is some local focus or caseating centre from 
w r hich the disease has become disseminated. And, no 
doubt, in many cases this is so ; a cheesy bronchial gland, 
some chronic otorrhcea, some scrofulous disease of the 
kidney or Fallopian tubes — something of this kind exists 
somewhere, and from hence the disease infects the glands or 
lymphatic tissues, and thus spreads by continuity of tissue, 
or from gland to gland, to produce the infiltrations and 
nodular growths with which we are all but too familiar. But 
this certainly is not always so ; miliary tuberculosis is, at 
any rate occasionally, found where, even after the most 
careful search, no caseous centre can be discovered. It is a 
disease, however, which seems particularly prone to outbreak 
in cases of this kind ; and chronic otorrhcea, with disease of 



ACUTE TUBERCULOSIS. 395 

the temporal bone, epiphysial and joint diseases in young 
people, cheesy disease of the bronchial glands, and scrofu- 
lous disease of the genito-urinary tract, are some of its more 
common precursors or sources of infection. 

Symptoms. — In its earliest stages, it is one of the most 
insidious and most difficult to be sure of in the whole range 
of the diseases of childhood. General malaise, pallor, 
wasting, fatigue, want of appetite, irritability of temper, 
slight fever, these are the indefinite symptoms which herald 
its onset, as they do that of many other far less serious 
maladies. The symptoms are not uncommonly so slight as 
to be attributed to worms or some trivial ailment by the 
mother or nurse. To the medical man the appearance, per- 
haps, betokens more than this, but he is at a loss between 
acute tuberculosis and typhoid fever, or some other debili- 
tated state which tonics will restore. Often he can only 
wait and watch, uncertain until the progressive emaciation 
and fever, perhaps enlargement of the liver and spleen, or 
more likely some few indications of disease in the lungs, 
compel him to relinquish hope. Sometimes he has hardly 
come to any conclusion, when intolerance of light, drowsi- 
ness, squint, are noticed ; quickly followed by convulsions, 
coma, and death". 

It is astonishing sometimes how much disease is found 
after death where there has been but little evidence during 
life. A boy of six years was lately admitted to the Evelina 
Hospital for slight jaundice. He had the appearance of 
being considerably emaciated ; his temperature was 99.6 ; 
his tongue red and dry, his lips over-red ; he breathed pecu- 
liarly deeply, 32 per minute, there was undoubted loss of 
resonance below the right clavicle, and bronchial breathing 
was heard in the inter-scapular region behind. The pulmo- 
nary symptoms, however, were not marked, and by these 
alone the nature of the case must have been at best doubt- 



396 DISEASES OF CHILDREN. 

ful ; but the spleen and liver were enlarged, and, with the 
jaundice, turned the scale decidedly in favor of acute tuber- 
culosis, for jaundice is not common at this age. It, and the 
enlargement of the liver and spleen, with evidences of ema- 
ciation and disturbed respiration, suggested tubercular dis- 
ease of the liver and general tuberculosis. Even now the 
opinion was not altogether an unwavering one, for the jaun- 
dice disappeared and the child improved and left his bed for 
a day or two. Then he had a relapse, and his temperature 
ran up to 104 , and he died seven weeks after admission. 
The most that his chest had revealed was a good deal of 
dry crackling, chiefly below the nipples and in the scapular 
region, and occasional moist sound in other parts. Dullness 
also came and went in an irregular fashion. At the autopsy, 
however, the lungs were stuffed with tubercle, and the bron- 
chial glands were caseous and softening. In the liver were 
many small nodules of bile-stained tubercle, such as have 
been ascribed to tuberculosis of the ducts. The spleen also 
contained many tubercles. 

Diagnosis. — As already stated, this is often difficult or 
impossible ; but inasmuch as it is a general disease, affecting 
all the viscera and serous membranes, help may sometimes 
be gained by detecting a slight pleuritic rub here or there, 
or any evidence of consolidation about the roots of the 
lungs. Hyperesthesia of the skin and muscular twitchings 
not uncommonly indicate tubercular formation in the spinal 
membranes, and any intolerance of light should be carefully 
considered. Any tubercle in the choroid or changes in the 
fundus oculi would make the diagnosis certain. It may be 
added, that a hard enlargement of the spleen may give 
occasional help, but we must remember that the enlarged 
spleen of typhoid fever is sometimes, in childhood, an 
unusually resistant one, and the disease is most likely to be 
overlooked or to be mistaken for typhoid fever. 



scrofula. 397 

Prognosis. — It runs a somewhat variable course, from 
three to six weeks ; but, so far as is known, is always fatal. 

Treatment. — Of late years, the hope has been indulged 
that some drug might be found to arrest the growth of the 
nodules of tubercle ; but iodide of potassium, quinine, per- 
chloride of mercury, salicylic acid, iodoform, turpentine, etc., 
have all been tried, and, as regards general tuberculosis at 
any rate, have been found wanting, and one cannot say that 
there is any recognized treatment. 

2. Scrofula. — Under this heading come diseases of the 
mediastinal and abdominal glands and other less-known 
conditions. The more common affections are : Caseous 
disease of the mediastinal glands, or bronchial phthisis ; 
Tabes mesenterica, or abdominal phthisis ; Caseous disease 
of the more superficial glands, or scrofula. To diseases of 
this kind also belong the various fleshy or lympho-sarco- 
matous growths, general or local, infiltrating or not infil- 
trating, as the case may be. Of this latter group, the com- 
plex of symptoms called Hodgkin's disease, or lymphatic 
leukaemia, forms a part. And the leucocythaemic condition 
may be conveniently considered in the same connection. 

The subject may be most intelligibly treated first, in a 
general way, by describing the different varieties of cases 
which come under notice before taking the local conditions 
seriatim. 

Starting thus from the simplest form of lymphatic hyper- 
plasia, and proceeding to the more complex, we may notice, 
first, the case of the child of six or eight years old, good- 
looking, or perhaps with the thick skin and irregular fea- 
tures supposed to denote scrofula, with chronic enlargement 
of the tonsils. The tonsils repeatedly inflame, and as often 
as they are examined, they show cheesy secretions filling 
their follicles and exuding from them upon pressure. By- 
and-by the glands in the neck at the angle of the jaw begin 
34 



398 DISEASES OF CHILDREN. 

to enlarge ; in one case, to suppurate quickly and subside 
again ; in another, to undergo a more slow process of en- 
largement, followed by caseation and slow ulceration which 
produces that scarring of the neck so often seen ; in another, 
to gradually develop into a huge localized tumor, with some 
caseation in parts, but in which the most noticeable feature 
is slow and continuous growth. In another class of cases, 
the local glandular enlargement slowly extends to other 
glands in the neighborhood ; then perhaps stops awhile, and 
then again extends, and so on, with fitful course. The 
glands on the opposite side become infected, still all casea- 
ting as they enlarge, and the enlargement not being of any 
great extent. Slowly the disease extends over the body, 
the child presenting an oscillating pyrexia, and gradually 
emaciating, till death comes by tuberculosis, or some disease 
of like character breaks out elsewhere — a spinal caries, a 
multiple epiphysitis, with caseous abscesses in the bones, 
and the chronic exhaustion of suppuration, lardaceous dis- 
ease, or nephritis. 

These are the cases called scrofulous. The picture may 
be drawn of one of these children, with fair hair, red eye- 
lids, ulcerated and bloodshot eye ; thick lips, spongy gums, 
offensive breath, and hard and dry skin. Unhealthy sores 
form on the skin, and the neighboring lymphatic glands 
enlarge, and although the sores slowly heal, the glands 
continue to increase ; others become affected, and, with a 
hectic fever, there is slow emaciation, without the least 
amelioration by good living or drugs. What the end of 
such a case may be it is hard to tell ; it may be acute tuber- 
culosis, a more chronic phthisis, bone disease, or scrofulous 
kidney. Examples in any number of all these varieties, and 
others intermediate, lie thick along the practice of every 
medical man. Happily, too, few are unfamiliar with excep- 
tions where the scrofulous condition, even in its worst 



scrofula. 399 

phases, sometimes strangely stops — perhaps for good, per- 
haps, alas, to light up again suddenly in later years. 

There is yet another group of cases ; that in which growth 
replaces inflammation. The commencement of such is much 
the same. A local tumor of fleshy consistence slowly arises 
in the glands — most often in the neck, perhaps in one axilla, 
more rarely in the groin. At first we think we have to do 
with the ordinary hyperplastic and caseating gland, and not 
unlikely some carious tooth may seem to start it ; but it goes 
on increasing, until at last a huge growth is formed, which 
buries the structures of the neck and chokes the patient. 
Dr. Goodhart has seen several cases of this kind. He gives 
a note of one, because it was carefully watched for some 
time by Dr. Dukes, of Rugby. It was that of a girl often. 
She had always lived at Rugby, and about six months 
before he saw her she had had dropsy following scarlatina. 
The glands in the neck became swollen three or four months 
later, commencing on the left side. A lump in the right 
axilla was noticed about the same time. The swelling of 
the glands in the neck gradually increased until it formed a 
nodulated elastic swelling, which uniformly distended both 
sides of the neck. The pulse was very rapid, and there 
was a short systolic basic bruit, but no other disease was 
evident. The lungs, the mediastinum, the liver, spleen, and 
blood were all normal. Dr. Dukes tried all manner of 
drugs, but without success, and the child died eighteen 
months to two years afterward of characteristic Hodgkin's 
disease, with general enlargement of all the lymphatic 
glands, though with but slight enlargement of the spleen. 
The submaxillary enlargement was so great as to obstruct 
the breathing. She was much wasted and extremely 
anaemic. 

In another case of this kind, a girl of seven, a mass of 
glands had been removed from the neck twelve months 



400 DISEASES OF CHILDREN. 

before ; but glandular masses still existed on both sides of 
the neck and in the left axilla. There was also some evi- 
dence of pressure on the right bronchus. The liver reached 
nearly to the umbilicus, and the spleen was large and firm. 
There was no excess of leucocytes in the blood. 

Here then are local tumors which correspond with the 
local inflammation ; two divergent results of local stimula- 
tion. But further than this, in the enlargement of the glands 
in one axilla, we see how liable the local disease is to be- 
come more generalized, and in the most advanced cases we 
see the glands rapidly enlarge all over the body ; the spleen, 
liver, and kidneys undergo characteristic changes ; the fundus 
oculi exhibits a form of hemorrhagic retinitis ; the body 
wastes; the child becomes anaemic; there is hectic fever, 
simulating that from the formation of pus, and death results 
from epistaxis ; bleeding from the gums; purpura; albu- 
minuria ; exhaustion, or some leukaemic form of pneumonia. 
But even this does not complete the chain of conditions. In 
these, the more common cases, the hyperplasia of the glands, 
although generalized, is still confined to the glands ; but 
occasionally this is not so, and the generalized gland dis- 
ease oversteps its boundaries, and spreads into other tissues. 
Dr. Frederick Taylor has published a case of this nature in 
a boy aged twelve, who had leucocythaemia, hypertrophy of 
the spleen and lymphatic glands, and fleshy lymphadeno- 
matous growths of the pleura, mediastinum, liver, kidneys, 
and epididymis. This child had a high temperature and 
purpura, and died with dropsy, scanty urine, labored breath- 
ing, and ulcerated gums. 

This case may, indeed, be regarded as typical in another 
way — viz., that the boy not only suffered from enlarged 
spleen, but he also had leucocythaemia. Some pathologists 
are inclined to regard the lymphatic leukaemia in which 
there is no increase of white blood-cells in the blood as 



SCROFULA. 40I 

absolutely distinct from the splenic form of disease, in which 
that is the most characteristic phenomenon ; but there is no 
doubt that cases such as this are occasionally met with in 
which the two forms of disease are combined. 

Now all these grades of lymphatic disease, inflammatory 
and hyperplastic, we may dissociate if we will, and consider 
singly. For instance, we may take the slow caseation of 
the glands, local or general, and calling it scrofula, discuss 
its relations with syphilis, with rickets, with any other form 
of malnutrition ; but the point is this, that studying the 
diseases of lymphatic tissues, not only does this particular 
disease exist, but that such a one is necessary to make the 
scheme of these diseases complete, and in accord with the 
changes that go in other tissues. Pathology, therefore, 
seems to teach that scrofula is, so to speak, a normal 
process of decay in lymphatic glands : one that is to be 
expected as an occasional thing under any circumstances 
of life, and, therefore, one that will certainly be aggravated 
by all causes of malnutrition — syphilitic, rachitic, or what- 
ever they may be. In the same way with the fleshy hyper- 
trophies or growths. We may, if it be convenient, take 
any one of the more common examples given, and give it 
a name — Hodgkin's disease, for example, where the lym- 
phatic glands are large, fleshy, caseating, but not softening ; 
where the spleen is like hardbake, from the yellow nodules 
it contains, and the liver and kidneys are diseased by an 
infiltrating lymphomatous growth. But the student will 
only be puzzled if he attempts to keep to arbitrary lines. 
There is a process of growth in the lymphatic tissues just 
as there is one for the skin in the way of papilloma and 
epithelioma ; it is only a question of more or less ; and all 
the conditions described form one series, the individual ele- 
ments of which are apt to combine. 

In thus attempting to make a disease which is puzzling 



402 DISEASES OF CHILDREN. 

to the student somewhat clearer from a pathological stand- 
point, confusion has not been made worse, more particu- 
larly as, except in regard to special symptoms and treat- 
ment, it seems unnecessary to say much here of some 
grades of this series. Such as do not admit of being thus 
dismissed now follow : — 

Scrofula. — From what has been already said, it will have 
been seen that cheesy enlargement of glands, unhealthy 
ulcerations of the skin and mucous membrane, and cheesy 
inflammation of bones and joints, are the characteristics of 
this disease. 

Some hold that it is due to a constitutional condition ; 
others that it is the result of local disease ; but, however 
this may be, the clinical course of too many cases undoubt- 
edly seems to show that the disease does spread from one 
part to another, and the risks attaching to it are based upon 
that clinical fact. The treatment of such cases will vary 
according as we hold the constitutional or the local element 
to be the more important ; but, given a case of cheesy en- 
largement of the glands of the neck, for example, one can- 
not but think, in prospecting the future of the child, that its 
risks lie in the local disease becoming generalized in some 
way by a process of infection ; or, to take the other view, 
by the constitutional something, of which we here see the 
local expression, breaking out in some more general 
manner. 

These two views are put thus pointedly for the purpose 
of discussing the treatment. Those who hold that the 
disease is a constitutional one treat it by general means — 
such as seaside air, well-ventilated living rooms, plenty of 
exercise ; and, internally, good food, cod-liver oil, iodide of 
iron, and tonics of all kinds. It is usually advised that any 
local irritation should be looked to, particularly enlarged 
tonsils and decayed teeth, and various remedies have been 



SCROFULA. 403 

suggested for acting upon the diseased glands. Chief of 
these are sulphide of calcium, phosphorus, chloride of cal- 
cium, and bicarbonate of sodium. The glands may be 
stimulated locally by iodine, and the child may be made to 
inhale iodine by keeping some crystals in a perforated 'pill- 
box in the room which it inhabits. Chloride of ammonium 
may also be used by inhalation. When one looks back 
over a long series of years, one cannot but admit that this 
plan of treatment has been in many cases successful — how 
often it fails there is but little opportunity of knowing — but 
in the immediate present it is far otherwise, and such cases 
may go on week after week without improvement until 
they are ultimately lost sight of. One is not therefore sur- 
prised that, with the doctrines of local infection, which have 
been advocated of late years. with much persistency, at- 
tempts have been made to cut the knot of medical power- 
lessness by an appeal to surgical aid, and chronic and 
intractable enlargements of glands are now frequently 
removed by the knife. There is one practical hindrance 
to the more general adoption of this method — viz., that 
these gland swellings are so common and have so long 
been treated by less severe methods that their nature is 
seldom regarded in its more serious aspects, and radical 
suggestions of this sort are often received with surprise 
and repudiation. Other means less severe are practiced 
by many surgeons, such as the local galvanic caustic sug- 
gested by Mr. Golding Bird, as being at once ingenious and 
useful to hasten the softening down and discharge of these 
caseous masses. These, however, are the two methods. 
The time is hardly yet come for a decision upon the value 
of the new method ; but, so far, it seems to be less 
satisfactory than the other. For, while the ordeal to be 
gone through in the way of operation is no slight one, the 
glandular masses have in several instances reformed within 



404 DISEASES OF CHILDREN. 

a short time of the operation. For the present, therefore, 
it seems wiser to keep on the old paths, and in the worst 
cases — certainly in the more localized swellings — where 
possible, to insist upon residence at the sea-coast, as the first 
necessity, and then to practice all those other measures of 
general hygiene alluded to. 

For the fleshy gland tumors, a resort to extirpation is 
more necessary, and should be proposed in young people 
when the growth is steady and threatening to become un- 
manageable. It is too late to do anything when the disease 
has extended to both sides of the neck. The glands must 
be removed when of moderate size, if treated in this way 
at all. 

Of the treatment of the more generalized growths and of 
leucocythaemia, it is hardly necessary to speak ; for, although 
many things have been tried, nothing has proved efficacious. 
In leucocythaemia, with enlargement of the spleen, it is 
worth remark that it has originated after malarial poisoning 
in a fair proportion of cases occurring in adults. 

Chronic enlargement of the spleen is not uncommon in 
childhood in several diseases, one of which is ague. It will 
be well, therefore, to keep a watch on all such cases. Pos- 
sibly, by so doing, leucocythaemia may in some instances 
be averted or arrested. 

Bronchial Phthisis. — By this is meant cheesy enlarge- 
ment, softening, or calcareous change in the glands of the 
mediastinum, whether anterior or posterior, but chiefly the 
latter, and the associated changes, if any, with which it may 
be accompanied in the lung. 

It has received from some authors a distinct name for two 
reasons — first, because some consider it may give rise to a 
special group of symptoms; and, secondly, because the 
disease in the lung is often characteristic. 

The existence of large and caseous glands in the medias- 



BRONCHIAL PHTHISIS. 4O5 

tinum is very common. Rilliet and Barthez say it occurs 
in 79 per cent, of all cases of phthisis in children. Indeed, 
this is the weak point of its specialty, for it certainly is of 
more frequent occurrence without any special symptoms 
than with them, and no doubt in many cases of this and of 
pulmonary phthisis nothing peculiar in the distribution of 
the latter disease can be demonstrated. Perhaps this diffi- 
culty in part arises from a want of consideration of the fact 
that bronchial phthisis may be either primary or second- 
ary. Sometimes the caseous disease of the glands is the 
primary disease, and the phthisis is a subsequent develop- 
ment ; in others, it is the direct result of the pulmonary 
tuberculosis. There can be no doubt that caseous disease 
of the bronchial glands precedes any tubercular disease of 
the lung in an appreciable number of cases, and there can 
be no doubt, from the observations of numerous writers 
both at home and abroad, that such enlargement is occa- 
sionally attended with peculiar and characteristic symp- 
toms. 

Inflammation of the bronchial glands can be traced in all 
its stages in the post-mortem room with great ease, from 
the frequency with which it occurs. We find the acutely 
inflamed or swollen, pink, soft gland ; we find the gray, 
swollen, more fleshy state of a later stage ; we see some- 
times the glands studded with gray miliary tubercles ; we 
see at others one part of the gland thus tubercular, another 
cheesy, and another, perhaps, acutely inflamed. It is quite 
common to see an old cheesy deposit in a gland, and fresh 
tubercle extending from its borders. We may see, again, 
the glands shrivelled into calcareous masses, with more or 
less fibrous matting of the parts about them, and sometimes 
with definite adhesions to the pneumogastric or its branches. 
There may be evidence that they have ulcerated into the 
oesophagus or bronchus ; and as regards the lungs and ad- 



406 DISEASES OF CHILDREN. 

jacent parts, miliary tubercle may spread from them to the 
adjacent pleura or pericardium ; or, as is more common, the 
lung is infiltrated on one side or both with cheesy or miliary 
tubercle, which, leading to solidification chiefly about the 
root, disseminates a miliary tuberculosis into the lung by' 
means of the bronchial septa. The glands may be much 
enlarged, and extend up into the neck along the sides of 
the trachea. They do not often lead to compression of the 
neighboring canals, either respiratory or circulatory ; but 
they tend to soften, to lead to mediastinal abscess, or, more 
commonly, to ulceration into the bronchus or oesophagus. 
It is thus that calcareous masses come to be expectorated, 
and that evidences of bygone disease are not unfrequently 
found in the post-mortem room. Thus it is that occasion- 
ally a child is suddenly choked by the entrance of a softened 
gland into the trachea by perforation of the tube. 

The disease in the glands is usually associated with pul- 
monary tuberculosis, and not rarely with the condition 
called cheesy consolidation. This change is apparently 
allied to that which has been denominated by Gee, " The 
chronic pneumonia which attends disease of the tracheal 
and bronchial glands."* 

The conditions under which disease of the glands is likely 
to be present are such as pertain to cheesy glands in general 
so far as any constitutional element predisposes to it ; but, 
locally, all the conditions of catarrhal inflammation of the 
trachea, bronchus, and lung, are the immediate cause, and 
thus whooping-cough, measles, rachitis, as causes of collapse, 
etc., are its most common precursors. 

Symptoms. — These will be detailed under the head of 
reflex spasm; but in addition to the. symptoms due to 
spasm, there are others which may be present due to press- 

* " St. Barth. Hosp. Rep.," vol. xm. 



BRONCHIAL PHTHISIS. 407 

ure of the enlarged glands upon the adjacent structures ; 
such are, occasional difficulty of swallowing, and puffiness 
or oedema of the face or parts about the neck. Haemopty- 
sis may occur, but its interpretation would be equivocal. 

As regards physical signs, dullness between the scapulae 
is rightly considered the most reliable ; it should always be 
carefully searched for over the fourth or fifth dorsal vertebra 
between the scapulae, and comparison made of the space on 
each side of the spine. If the glands are large, some dull- 
ness may reasonably be expected. The manubrium sterni 
and the parts on either side of it should also be examined, 
for although disease in the anterior mediastinum is much 
more rare, it is now and then present and dullness can be 
detected. A comparison of the breathing on the two sides 
often adds much to our information, some difference on the 
one side or the other being detected — in the way of bron- 
chial breathing, bronchophony, or even crepitation — or 
some deficiency or harshness of respiration being discerned 
on one side or the other. 

Eustace Smith calls attention to the occasional existence 
of a venous hum in these cases, due to the pressure of the 
glands upon the innominate vein. It may be best produced 
by bending the head backward, so that the face is hori- 
zontal and looking to the ceiling. 

The general symptoms of phthisis, wasting and hectic, are 
so frequently part of the clinical picture, that they also must 
be considered to be symptoms of the special disease. 

Diagnosis. — Such cases often escape notice by reason of 
want of care in seeking for them. The most powerful means 
for their detection is the ever-present memory of the fre- 
quency of their occurrence, but it must also be remembered 
that the symptoms of spasm may be very intense, and the 
disease under such circumstances may be mistaken for 
spasmodic asthma, or even for some local laryngeal disease. 



408 DISEASES OF CHILDREN. 

Intra-thoracic tumors, though not common in childhood, 
might possibly on an occasion mislead us. 

Prognosis. — This is always grave. The disease is too 
fertile a source of pulmonary tuberculosis to allow anything 
but fear for the result when once the existence of enlarged 
glands has been positively determined. But the general 
appearance, the existence of progressive emaciation, of 
pyrexia, and so on, must be taken into account. If the child 
is gaining flesh, not feverish at night, or showing other signs 
of ill-health, there is no reason for being over-anxious ; for 
if the post-mortem room gives too abundant evidences of the 
risk, it gives much evidence also of the tendency to cure of 
these caseous glands. 

The treatment has already been given. It consists of 
sending the child to the seaside, and keeping it there; 
giving it good digestible food, and seeing that it digests 
what it eats; and administering iron, iodine, cod-liver oil, 
etc., internally. 

3. Tabes Mesenterica and Tubercular Peritonitis. — 
Abdominal tubercle is found under two or three varieties 
— Tabes Mesenterica, Tubercular Peritonitis, and an inter- 
mediate condition, not well separable from either, in which 
a layer — sometimes of considerable thickness — forms upon 
the surface of the serous membrane, sometimes between the 
diaphragm and liver, sometimes in the omentum, or upon 
the surface of the intestines uniting it with the abdominal 
wall. All these conditions are often more or less combined. 

Tabes Mesenterica (caseous or tubercular disease of 
the mesenteric glands) is not uncommon; nevertheless, 
it is rare indeed in comparison with " consumption of the 
bowels " which is so often heard of in the dwellings of the 
poor. From a large out-patient department at the Evelina 
Hospital, during several years, and when at least 6000 or 
7000 children must have come under observation, and pro- 



TABES MESENTERICA. 4O9 

bably considerably more, the author has notes of only forty- 
six cases, and half of these were of doubtful nature. Some 
few others are to be found associated with phthisis, but as a 
substantive ailment we might have supposed it to be more 
common than it is. Many diseases simulate it for a time. 
A child wastes and the stomach enlarges as a result of 
chronic indigestion from unwholesome food, uncleanliness, 
and bad air. It wastes because it is starved, and the stomach 
grows large, or apparently so, from flatulence combined with 
a tendency to contraction of the lungs and collapse which 
exists in feeble children. No doubt, too, in these conditions 
is laid the commencement of many a true case of tabes 
mesenterica, but it is unsafe to draw any conclusion upon 
the nature of the disease until such time as a child has been 
subjected to prolonged watching and careful treatment. 
Hundreds of cases like this get rapidly well under proper 
attention, while it is the tens only, or even the units, which 
have tubercular disease of the mesenteric glands. 

Symptoms. — These are indefinite ; wasting, increase in 
size of the abdomen ; abdominal pain and griping after food, 
followed by diarrhaea, are the principal. On a more minute 
examination the nightly temperature is febrile. But it is 
not uncommon in making inspections to find early, and 
sometimes moderately advanced, cheesy swelling of the 
glands which had not been suspected, and where, therefore, 
it must be supposed they had given no indication of their 
presence. In later cases there is some superadded ulcera- 
tion of the bowels which may be the cause of the diarrhoea ; 
sometimes tubercular peritonitis, which explains the pain. 
The abdominal wall is often natural, or, if swollen, soft and 
easily depressed ; occasionally it is even retracted, so that it 
is very difficult indeed to say what are certainly the symp- 
toms of uncomplicated tabes mesenterica. The only certain 
indication is the detection of the glands themselves by 



4IO DISEASES OF CHILDREN. 

palpation through the abdominal wall. But even here it 
has always seemed that this sign is of little value when it 
is most wanted, viz., in cases of early disease. However, 
it must be looked for in all cases by careful palpation round 
the umbilicus, by pressing backward towards the spine, and 
also by manipulating the abdominal wall between the two 
hands from side to side. The possibility of the detection of 
the glands, unless they be of very large size, will depend a 
good deal upon the state of the intestines. If the bowels 
be much distended with gas, they will be overlooked. 
Therefore repeated examinations must be made, and in 
cases of doubt an enema should be administered and the 
examination conducted shortly after its action. Dr. Good- 
hart has several times reached enlarged glands in this way 
that were not palpable from the surface, and has already 
hinted, as a possibility, that attention to the bulk of the 
material passed may sometimes help in the diagnosis of the 
state of the mesenteric glands. In advanced cases the 
mass is large, the body thin, the intestines often retracted, 
and then there will be no difficulty in detecting the disease ; 
but these are cases in which the general features of the case 
have already left little doubt. Moreover, in these cases 
what appears to be a mass of glands may eventually turn 
out to be not so much glandular as due to coils of matted 
intestine. 

In long-standing cases, too, other conditions arise which 
help toward the diagnosis, if any help be needed ; the cheesy 
glands infect the peritoneum in their neighborhood, and 
adhesions occur between the intestinal coils, and between 
them and the abdominal wall. It is then that irregular dis- 
tention of the abdomen is liable to occur, and much intes- 
tinal gurgling and rumbling, as in chronic stricture in the 
adult. Sometimes the tubercular disease spreads from the 
hypogastric region upward to the umbilicus, when a hard 



TABES MESENTERICA. 4 1 I 

indurated cord or ring is felt around the umbilicus, and a 
fecal fistula may form. Sometimes a general tubercular 
peritonitis arises with ascites. In these cases the fever is 
considerable, and the pain also, and the course of the dis- 
ease tends to be rapid. Softening of the glands is only 
occasional. It occurs now and then, and either leads to 
ulceration into the intestines, or to localized abscesses 
among the intestinal coils. Hitherto reference to the state 
of the mucous membrane of the bowel has been avoided, 
because the subject is a difficult one. Most authors treat 
of tabes, and rightly so, as a primary disease, and ulceration 
of the bowel as a complication. But, as a matter of fact, 
the two are so constantly associated that it is impossible to 
separate them, and it may almost be said that the presence 
of the one compels the existence of the other. It may be 
quite true that 'calcified glands may be found in the 
mesentery without any definite- evidence of former intestinal 
ulceration. Nevertheless, it is exceedingly rare in any case 
of recent disease to find the intestine absolutely free from 
ulceration, and hence it is that it is so difficult to say which is 
the more common mode of commencement — by ulceration 
of the intestine or by disease of the glands — for in any case 
swollen, yellow, enlarged solitary glands are likely to be 
found in various parts of the small intestine, some of them 
ulcerated, and showing raised yellowish edges with vascular- 
ization of the mucous membrane around them, or else large, 
irregular, thick-edged chronic ulcers. These have tuber- 
cular granules on their peritoneal aspect, and often ad- 
hesions and communications between one coil and another, 
such as make a complete examination of the intestine 
impossible. 

The severity of the diarrhoea will in a measure, though 
not altogether, depend upon the extent of the ulceration. 
The motions passed in these cases are usually liquid, dark 



412 DISEASES OF CHILDREN. 

brown, and offensive. They sometimes, but not often, con- 
tain small coagula of blood. 

The pain which some children suffer in advanced cases 
is very distressing. It seems to be of a severe griping 
character, which by its frequent recurrence keeps them in 
perpetual misery. 

Morbid Anatomy. — It hardly seems necessary to say more 
than has been said already upon tabes mesenterica. Two 
points, however, may be emphasized, (i) that calcareous 
glands are not uncommon in the post-mortem room ; (2) 
that disease of the mesenteric glands is only exceptionally 
present unless it is accompanied by ulceration of the intes- 
tinal mucous membrane. The infrequency of ascites in 
these cases may also be alluded to. It seems possible that 
this may be due to the slow progress of the disease, during 
which adhesions are formed between various parts of the 
abdominal cavity, with, in a- great measure, destruction of 
the serous membrane. Ascites is the usual accompaniment 
of tubercular peritonitis — that form of disease in which the 
peritoneum is covered with sandy-looking grains ; but this 
is an acute form of disease, and more commonly spreads to 
the still healthy serous surface from some cheesy mass in the 
omentum or between the liver and diaphragm. 

Localized patches of tubercle in the peritoneum are, 
indeed, quite common in most cases of tubercular ulceration 
of the intestine ; but the difference is the same between these 
cases and those of generalized peritonitis as between chronic 
phthisis and acute tuberculosis of the lung. Here we have 
a chronic and acute tuberculosis of the serous membrane. 
The tendency which miliary tuberculosis of the peritoneum 
shows to be associated with miliary tubercle of other serous 
membranes, the pleura in particular, may also be noted. 

Diagnosis. — This is only to be made absolutely by being 
able to feel the glands. But wasting, nocturnal fever, 



TABES MESENTERICA. 413 

abdominal pains, and brown, watery, offensive evacuations, 
combined perhaps with such slight local abdominal indica- 
tions as fullness, lumpiness, etc., will often make this nearly 
certain. 

As regards the glandular lumps, fecal accumulations are 
often puzzling ; the question between them must be decided 
by having recourse to enemata and frequent examination, 
both externally and by the rectum. Hillier and Rilliet and 
Barthez allude to cases in which cancer of the abdominal 
viscera caused some difficulty — one in the pancreas, the 
others in the kidney. Such conditions can, however, but 
rarely trouble one, although large tumors of the kidney 
are not uncommon. It is, perhaps, of more importance to 
distinguish, if possible, between tabes mesenterica and 
those cheesy masses to which allusion has been made 
at the commencement of the chapter; for although they 
are often combined, yet cheesy masses of this kind some- 
times run a very chronic course, and may ultimately 
disappear. 

Prognosis. — In former times tubercular peritonitis and 
tabes were looked upon as hopeless. But, latterly, for both 
these diseases good evidence has been shown that they may 
recover. Dr. Habershon mentions a patient, who, thirty or 
forty years before her death from tubercular meningitis, 
suffered as it was supposed from tubercular peritonitis, and 
this opinion was confirmed at the autopsy. It may be 
reiterated, for it is an energizing fact, amid much that is 
grave and disappointing, that calcareous relics, by their 
presence upon the post-mortem table, not infrequently 
give evidence of the spontaneous cure of cheesy glands. 
Surgeons in operating upon ovarian and other abdominal 
tumors, have sometimes seen tubercular disease of the 
serous membrane, and the patients have nevertheless 
recovered ; and, lastly, it may be added that it is the im- 
35 



414 DISEASES OF CHILDREN. 

pression of many physicians that these cases are by no 
means hopeless. 

The outlook will necessarily be grave ; the result, in the 
majority of cases, fatal ; but anything which makes for re- 
turning health, such as absence of fever, diarrhoea, wasting, 
etc., may be seized upon as an indication of hope. 

Treatment. — However much one may hold to the con- 
stitutional origin of tabes, no one can hesitate to attrib- 
ute much of the immediate outbreak to catarrhal states 
of the mucous membrane of the bowel, and to the ab- 
normal work which falls upon the glands in consequence 
of inflammation and other conditions, the result of im- 
proper feeding ; and no one, also, can refuse to admit that, 
with the lacteals largely blocked and the glands practically 
destroyed, the preservation of life from starvation and the 
remedy for the disease must largely lie in the careful adap- 
tation of a diminished work to the diminished capacity of 
doing that work. In other words, the cardinal treatment 
of tabes mesenterica consists in the most strict attention to 
dieting the patient; giving no more food than is necessary, 
and seeing that the quality of that which is taken is such 
that the intestinal lacteals may have as little work to do as 
possible. To this end it seems that beef juice, mutton broth 
freed from fat, chicken broth, eggs, and light fish afford the 
most appropriate diet. Milk and suet and fats should be 
given more sparingly, and carefully watched ; their assimi- 
lation can be accurately gauged by the state of the evacua- 
tions and the gain of weight under their administration. If 
they are digested, well and good ; if not, it is better to with- 
hold them for awhile. Fat may in a measure be replaced 
by sugar under such circumstances, the absorption of which 
goes on readily, while vigorous inunctions may in some 
degree replace the fat which is temporarily withdrawn from 
the intestinal canal. Not only so, it may be as well in some 



TABES MESENTERICA. 415 

cases, by the aid of the various digesting fluids which are 
now prepared, to get as much digestion accomplished out- 
side the body as is possible. The stomach will thus do 
more, the diseased surface less, and some rest will be given 
to the latter, so as to allow of the establishment of a more 
healthy state. 

As regards drugs, there can be no doubt of the good effect 
of tonics, such as iodide of iron and the various phos- 
phatic preparations, whether phosphites or phosphates. As 
regards cod-liver oil, it is generally given too indiscrimi- 
nately, and often in too large quantity. Its digestion should 
be carefully watched, the child frequently weighed, and its 
evacuations examined, so that no more may be given than 
is well disposed of. Inunction, again, is a capital plan for 
administering the oil, but it is so repulsive a way that it 
cannot be strongly recommended, and in most cases olive 
oil is to be preferred for this purpose. Of other remedies, 
chloride of calcium is of value, and, perhaps, small doses of 
iodoform. The former may be given to children three 
years old in five-grain doses with licorice, and the latter 
about half a grain. If any lumps can be felt near the sur- 
face, a five per cent, solution of the oleate of mercury may 
be painted over, the surface of the abdomen for four or five 
days, and repeated again at frequent intervals. In cases 
where there is much abdominal pain, small doses of Dover's 
powder are very useful ; two and a half grains may be given 
to a child of four or five twice or three times a day, if neces- 
sary. The child should be kept very warm, and removed 
to some dry inland air, or to some bracing seaside place. 

Tubercular peritonitis is best and sometimes very suc- 
cessfully treated by the local application of mercurials. 
Some oleate of mercury may be painted over the abdomen, 
or a preparation of the ung. hydrarg. 5j, ext. bellad. 5j, and 
glycerinae f§j. Either of these painted over the abdomen 



416 



DISEASES OF CHILDREN. 



night and morning for three or four days will, perhaps, 
make the skin a little sore, if so, they may then be discon- 
tinued for a day or two, to be resumed in due course. 
Should there be much pain, warm linseed-meal poultices 
may be applied over the ointment; and for cases in which 
there is much ascites, it is advisable to remove the fluid and 
envelop the abdomen with strapping, bandages, etc., so as 
to prevent, if possible, the accumulation of fluid, and to 
keep the parts quiet so that adhesion may take place. The 
quiescence of the parts affected may be further encouraged 
by small doses of opium given internally. These cases are 
usually accompanied by fever, and the child is therefore 
necessarily kept in bed, and upon fluid diet. Should the acute 
symptoms subside, the abdomen should be well swathed in 
flannel ; tonics should be administered, and the child taken 
as soon as possible into some good seaside air. 

4. Infantile Syphilis. — Hereditary syphilis plays a large 
part in the diseases of infancy, and is of great frequency 
among hospital out-patients. The ages of 158 cases under 
the treatment of Dr. Goodhart were as follows : — 



3 weeks 1 

4 « 2 

5 « 6 

6 " 6 

7 " 5 



8 weeks 


10 


4 


months 


14 


9 


months 6 


9 " 


7 


5 


" 


6 


10 


4 


10 


8 


6 


a 


10 


11 


" 3 


12 " 


21 


7 

8 


it 
u 


" 6 
7 


12 


< J 2 



Ten others were between one and two years, and twenty- 
four cases occurred in older children. 

As is well known, syphilis is a common cause of miscar- 
riages and premature births, and it occasionally shows itself 
in the child at birth. But it is much more common in in- 
fants of a few weeks old, and from the fifth or sixth week 
up to the fourth month appears to be its favorite time. In 
most of such cases the tale is that " it was a beautiful baby 



INFANTILE SYPHILIS. 417 

born," and perhaps at a month, six weeks, two months, etc., 
a rash begins to appear. 

Symptoms. — These are those of secondary syphilis in the 
adult, of the eruptive stage of an exanthem ; but they are 
somewhat less regular than in adults. As Mr. Hutchinson 
puts it, " the tertiary and secondary stages are sometimes 
strangely mixed" — to wit, the frequent occurrence of bone 
trouble in children at the same time as the cutaneous erup- 
tion. It is probable that the symptoms are more regular 
and more severe the more recently either or both parents 
have suffered from the acquired disease. 

When syphilis occurs at birth the child is likely to be a 
shrivelled-up mite with a feeble cry, and a skin of a coppery 
color with scaling cuticle. The mouth and lips may be fis- 
sured and thick, the edge of the anus or buttocks ulcerated, 
and the soles of the feet red or coppery and scaling. In 
the worst cases the entire body may be covered with moist 
and brownish scales or crusts, and here and there blebs 
containing serum or sero-purulent material — a state of 
things which has been called syphilitic pemphigus, though 
" bullous syphilide " would be more appropriate. Most of 
these very early and severe cases die. They take food 
badly, and become exhausted. 

If we take a case in somewhat older infants, if the disease 
be severe, except that the child will in all probability be in 
plumper and better condition, its surface will be much in the 
same state. There will probably be a raised coppery erup- 
tion, with delicate scales or scurf covering its surface, and 
with serpiginous margin, spreading over the head, face, and 
trunk. The eyebrows may have come out, the nose and 
lips will be thick and fissured, perhaps small mucous tuber- 
cles will be visible at the angles of the mouth or the corners 
of the eyes, the nasal mucous membrane thick and the child 
" snuffling " — some think from mucous patches in the nose ; 



41 8 DISEASES OF CHILDREN. 

there will very likely be bullae or small ulcers about the 
penis and scrotum, condylomata about the anus, and scales 
of some thickness about the soles of the feet, and possibly 
the palms of the hands. In these severe cases the liver 
and spleen are not often affected. 

In milder cases there is snuffling, more or less of a squamo- 
tubercular rash or a coppery roseola of irregular blotches, 
with fewer scales ; perhaps a fissured anus, with condylo- 
mata. The syphilitic infant will sometimes present a dirty 
tint of face, called the cafe-au-lait tint ; but this is more 
common in the severer than in the milder cases, in which 
the child, although the symptoms are so pronounced as to 
leave no doubt about the malady, may be plump and good- 
looking. 

Perhaps it should be added that the composite of symp- 
toms is very varied. Let us take a few. In one case — a 
child of eight months — there was a well-marked cafe-an- 
lait tmt, craniotabes, small circular ulcers in numbers round 
the anus, and a history of snuffles. In another, snuffles 
and craniotabes only. In another, a well-marked coppery 
scaly-syphilide round the mouth. In another, snuffles, 
thick lips, depressed alae nasi, and red indurated gumma- 
tous lumps in the skin of various parts of the body. In 
another, no evidence of the disease save condylomata and 
perhaps snuffles (this is a very common case). In another, 
a bullous eruption, followed by condylomata. In another, 
a diffused redness of the soles of the feet and the palms of 
the hands, with a faint maculation of the buttocks^ and legs. 

As regards the rash upon the skin in congenital syphilis, 
a gyrate scaly eruption, with slight thickening (the squamo- 
tubercular syphilide or syphilitic psoriasis) seems to be 
more common than a macular syphilide, or syphilitic 
roseola, as it has been called. A diffused redness and scal- 
ing of the soles of the feet is also very common ; so, too, 



INFANTILE SYPHILIS. 4I9 

are snuffling, Assuring of the lips, and mucous patches at 
the angle of the mouth, fissures of the anus, condylomata, 
superficial ulcerations over the buttocks and scrotum, inter- 
trigo, etc, As rarer conditions, furuncular eruptions may- 
be mentioned — red indurated masses in the connective 
tissue — which suppurate, if at all, very slowly and by a 
small aperture in the skin. Sometimes the skin presents 
circular coppery patches, in the centre of which the cuticle 
is slightly raised and translucent, looking as if about to 
form a bleb. In others there may be an annular eruption, 
with the skin in the centre healthy, and not altogether 
unlike patches of tinea. Bullous eruptions are not very 
uncommon, but the bullae are often only represented by 
circular or oval superficial abrasions or crusts. 

Once, Dr. Goodhart saw a condition intermediate between 
these two cases last mentioned — a child of four months, in 
whom, distributed over the body, but chiefly on face and 
scalp, were slightly raised, circular, flat, brownish spots, 
which vesicated superficially, and then dried in the centre 
into a brown crust. The condition spread by circular ripples, 
and left superficial ulcers, which rapidly healed under 
mercurial treatment. 

In bad cases the skin generally will assume a brown, 
thickened, wash-leathery consistence, from diffused chronic 
dermatitis. 

Syphilis sometimes causes extreme anaemia. 

Laryngitis is very common, as may be judged from the 
frequency with which hoarseness is met with. Henoch 
attributes this, and no doubt with some probability, to the 
formation of mucous tubercles about the larynx ; but so far 
as is actually known, a more general thickening of the mu- 
cous membrane of the epiglottis takes place, such as is so 
common in adult life. Sometimes extensive ulceration 
occurs ; an instance of this, in an infant of four months, is 



420 DISEASES OF CHILDREN. 

recorded under the head of diseases of the larynx. Some- 
what severe laryngeal symptoms occurred eleven times in 
the series of cases given, but in one case the author is not 
sure that the symptoms may not have been due to iodism. 
The child was three months old, and was only taking fifteen 
drops of the syrup of the iodide of iron three times a day. 
This it had done for ten days ; a grain of hyd. c. cret. 
being given twice daily in addition. Suddenly, when the 
rftacular syphilide was disappearing, a most profuse muco- 
purulent discharge began to come from the nose, with much 
hoarseness also, and subsequently angry boils appeared in 
various parts of the body. 

Hepatic and splenic enlargement occur not infrequently, 
the latter far more commonly than the former. Dr. Gee 
says the spleen is palpable in about one-half the whole 
number of cases. The author does not put the propor- 
tion so high. It would appear that hepatic enlargement 
but seldom occurs by itself, for, of seventeen cases, eleven 
were simple enlargements of the spleen — in the remainder 
both liver and spleen were large. Dr. Goodhart has no 
note of any case of hepatic enlargement alone. 

For much that is interesting regarding the pathology of 
bone syphilis the reader must be referred to what has been 
said under the head of rickets. It is only necessary to 
repeat now that of late it has been contended, particularly 
by M. Parrot, that there is a syphilitic form of disease of 
the cranial bones, as well as one which attacks the epiphysial 
ends of the long bones. The disease of the cranium is 
characterized by a velvet-pile-like growth of bone upon the 
outer surface of the skull, which spreads over the bones 
around the anterior fontanelle, between the sutures and 
the centres of ossification. Thus the sutures come to form 
furrows, and the calvaria is bossed. In company with the 
new bone formation goes a process of softening and atro- 



INFANTILE SYPHILIS. 42 1 

phy, and thus the occipital bone is usually, and the other 
parts are occasionally, thin, soft and compressible (cranio- 
tabes). That this form of skull is found in syphilitic infants 
there is no doubt whatever; that it is found in syphilitic infants 
who are quite moderately rachitic there is also no doubt ; 
but whether it is ever present in infants who are free from 
all traces of rickets is doubtful ; and how much of the 
diseased process is due to the one disease, how much to the 
other, or how much to some combination of favoring influ- 
ences, is very uncertain. This much, however, may again 
be insisted upon, that syphilis is an energetic producer of 
new, though oftentimes of bad, bone. Rickets is pre- 
eminently a cartilage former. The exuberance of bony 
deposit is therefore in favor of syphilis rather than of rickets, 
which, even in its reparative stages, is not generally known 
by a propensity of this kind. The disease, as it is' seen in 
the ribs, is difficult to distinguish from the changes of 
rickets, unless, as is sometimes the case, it occurs in parts 
of the bones other than those bordering upon the costo- 
chondral articulation. As to the lesions in the other bones 
there is less doubt. They are certainly, in the main, quite 
distinct from rickets. The bone at the junction of the epi- 
physis with the shaft undergoes a slow caseous inflamma- 
tion ; more or less periosteal bone is developed from the 
epiphysis upward along the shaft, giving rise to consider- 
able thickening ; subsequently an abscess forms, and the epi- 
physis becomes separated from the shaft. At the same time, 
the medullary parts of the diaphysis undergo atrophic 
changes by the overgrowth of a gelatinous medulla, and 
there are also minor changes of irregular ossification and 
calcification, such as might be expected from such an inter- 
ference with the natural processes of ossification. Here, 
again, as compared with the usual run of rachitic bones, 
syphilis is known by the amount of bone which is found in 

36 



422 DISEASES OF CHILDREN. 

the periosteum ; and in such cases as the author has seen 
there has been no evidence whatever of the growth of car- 
tilage which characterizes rickets. It has not been his 
experience that many bones are liable to be affected at once ; 
three times only out of seventeen was it so. In the series 
of 158 cases, seventeen were examples of bone disease, not 
including craniotabes. They were mostly cases of what 
might be called nodes, but once or twice abscesses formed ; 
in one case both elbows suppurated. The elbow was the 
seat of the disease eight times ; the shoulder twice ; the 
wrist thrice ; the finger once ; the knee twice ; the middle 
of the shaft of the tibia once ; the ribs twice ; the cranial 
bones twice. (The multiple lesions are counted separately.) 
The spleen was enlarged in three cases of bone disease ; 
the liver and spleen together once. In most of the cases 
there were other well-marked evidences of congenital 
syphilis. 

The following case may be given as an illustrative one : 
A female child of six months was brought to the hospital 
for swollen joints of six weeks' duration. One child had 
been born dead, and when three months old this child had 
been covered with an eruption of some kind. The child 
was very small, with snuffles and a depressed nasal bridge ; 
the lower lip was deeply fissured, and the body was covered 
with small coppery blotches ; the buttocks were ulcerated ; 
the anus swollen and fissured. The two elbow joints, the 
left wrist and shoulder, both knees, and the left ankle, were 
considerably swollen, the joints being more distorted than 
is usual in rickets. The ulna and radius had a nodular 
thickening just below the articular surfaces of the elbow, 
the humerus a thickening above. A similar condition 
obtained in the other bones — viz., a nodular thickening just 
above the joint, and not quite continuous with the articular 
end of the bone ; the left knee and wrist were painful ; there 



INFANTILE SYPHILIS. 423 

was slight nodular swelling of the rib cartilages at the junc- 
tion with the bones ; the spleen was hard, and extended 
down to the umbilicus ; the liver extended half-way to the 
umbilicus. 

The disease is one that occurs in very young children — 
from five weeks old. Three cases occurred in infants of 
two months and under; five at three months and under; 
three at four months and under; the remainder being six 
months or more. It causes a good deal of pain, and per- 
haps advice will be sought for the child, because, as in 
some cases of rickets, it cries whenever it is moved, or 
a limb appears to be paralyzed. When the disease has 
advanced sufficiently far to produce separation of the epi- 
physis, there may possibly be a faint crepitus obtainable. 

The immobility of the affected limbs has been called by 
M. Parrot syphilitic pseudo-paralysis, to distinguish it from 
infantile paralysis of neural origin ; but it must be added 
that Henoch describes cases of paralysis — chiefly of the 
arms — in syphilitic infants, in which there were no evi- 
dences of bone disease. These cases must, however, be 
difficult to distinguish with certainty, because, in addition 
to the bone affection, the tendency to muscular inflammation 
— well known in adults — cannot be altogether excluded. 

There is, however, no reason to doubt that, as in adults, 
the nervous system suffers also in congenital syphilis, peri- 
pheral neuritis, for example, would seem to be a very likely 
occurrence, and Dr. Thomas Barlow has recorded two 
cases* — one a female infant of a month old, with menin- 
gitis, arteritis of the cerebral vessels, and choroiditis ; the 
other a male of fifteen months, with gummata on the cranial 
nerves and disease of the cerebral vessels. 

Ulceration of the tongue, of all degrees, is very common 

* "Trans. Path. Soc, Lond.," vol. xxviii, p. 287 et seq. 



424 DISEASES OF CHILDREN. 

in congenital syphilis, though the author has more often 
seen a dorsal ulcer of some size and depth than a more 
superficial and generalized condition. Mr. Hutchinson, 
however, speaks of a diffuse stomatitis without ulcers, 
parallel to, and one may suppose part of, the general swell- 
ing which attacks the nasal mucous membrane. 

Of other rarer conditions, iritis and choroiditis may be 
mentioned as occasional occurrences, and a gummatous 
testis also. Henoch tells of several of the latter group of 
cases, and mentions others recorded by different observers. 
Mr. Hutchinson has recorded twenty-three cases of iritis, 
the majority in girls about the age of five weeks. It is 
liable to be overlooked, as the cornea was generally clean. 
(Fagge, " Pract. of Med.," vol. I, p. 134.) 

Morbid Anatomy. — This division of the subject is not 
extended, but, although definite lesions form the exception, 
syphilis is a fertile source of infantile atrophy, and some- 
times of multiple visceral lesions. For example, there may 
be pleurisy ; the lung may be in that condition of consolida- 
tion which has been called white hepatization ; the bones 
may show the changes already described ; the liver may 
contain gummata, or, as is more usually the case, may be 
hard or elastic and large, not much altered macroscopically, 
but much so microscopically — the lobular arrangement 
being broken up by a diffused fibro- cellular growth, which 
some have thought to be derived from Glisson's capsule, 
others from the activity of growth of the hepatic cells them- 
selves. The spleen, in like manner, may be large, dark- 
colored, hard, and traversed by tough fibrous bands ; while, 
as rarer conditions, Coupland has found in a female child 
of three months, not only gummata in the liver and lung, 
but also interstitial myocarditis and nephritis.* 

* "Path. Soc. Trans," vol. xxvn, p. 303. 



INFANTILE SYPHILIS. 425 

Sequela. — Congenital syphilis, once cured, is not liable 
to relapse — at any rate, so far as the eruption is concerned ; 
though an occasional condyloma may show itself about the 
anus or angles of the mouth, and perhaps a sore throat or a 
laryngitis develop. The chief peculiarity about the disease 
is that sometimes, not very often, it shows itself by symp- 
toms quite distinct from those which occur in infancy. Of 
these the more characteristic are interstitial keratitis and 
teeth of a peculiar shape and arrangement. But these go 
with several other signs — to wit, a stunted development, 
distorted bones (either bent or nodose), a sallow lack-lustre 
skin, a sunken nose, and a fissured mouth. There may 
even be deafness, aural discharge, ozaena, chronic ulceration 
of the palate with perforation into the nose, and unhealthy 
abscesses in various parts of the body, which may give rise 
to nasty discharges. Some of these cases are very puzzling ; 
the thickened bones, with much irregularity of the surface, 
and perhaps curvature and caries, the unhealthy abscesses, 
and ozaena, compel us, in the absence of proof, to halt 
between syphilis and struma. 

Hutchinson calls these tertiary symptoms. Indeed, as in 
the adult, so also in the infant, the eruptive or secondary 
stage passes off, and health is regained, perhaps for good. 
Yet after a variable interval further symptoms may be 
developed such as those detailed. The lesions are usually 
symmetrical. The appearances of interstitial keratitis vary 
according as it is recent and acute or of old date. 

Hutchinson's description of the disease is practically as 
follows : It is more common in girls than in boys. In the 
acute stage both corneae are usually affected, and they 
become of a bluish opacity, due to the effusion of lymph 
into their substance. There is a zone of ciliary congestion, 
but no ulceration. There is considerable intolerance of 
light. The inflammation over the opacity clears consider- 



426 DISEASES OF CHILDREN. 

ably, but leaves opacities of a nebulous appearance, which 
are easy to overlook. The permanent teeth are peculiar, in 
being set with much irregularity, in being dwarfed, deformed, 
and tending to decay. The upper central incisors have a 
vertical central notch of a more or less crescentic shape ; 
the canines are deformed, the crown of the tooth being 
peggy or pointed ; the molars may be dome-shaped ; all 
the teeth are small, and thus gaps are left between them. 

These various symptoms may be found at all ages, from 
seven or eight years up to eighteen or twenty, or even 
further. Hutchinson has repeatedly seen patients of various 
ages, from twenty to eight and twenty, become the subjects 
of syphilitic keratitis for the first time. 

Congenital syphilis is contagious, just as secondary 
syphilis in the adult is ; therefore no healthy woman should 
be allowed to suckle a syphilitic infant. 

Diagnosis. — The chief difficulty lies in the frequent failure 
of many of the characteristic symptoms. A large number 
of children have no symptom but snuffling, which is sus- 
picious, but not pathognomonic ; others perhaps have cra- 
niotabes; others laryngitis and an enlarged spleen, or an 
enlarged spleen and a dirty anaemic tint of the face, and so 
on. Thus it often happens that a doubt remains; and this 
is so, even if the most careful inquiries be made as to the 
parental illnesses — sore throat, rheumatism, eruptions, mis- 
carriages, etc. At all stages of its history syphilis trails the 
scent of scrofula, and the evidence one way or the other 
must be balanced as well as may be. 

Prognosis. — Many children waste and die during the pro- 
gress of the eruptive stage ; but, if seen early and subjected 
to treatment, a great many recover, and may lose all traces 
of the disease, save for such scarring of the face or trunk as 
may be left behind by the former eruption. Dr. Goodhart 
has known epilepsy to occur in older children who have 



INFANTILE SYPHILIS. 427 

suffered in this way. The severer generalized bullous forms 
of eruption are highly dangerous, and, if a child wastes 
persistently under treatment, the position is one of much 
gravity ; the same is true if there be much diarrhoea, 
snuffles, or bronchitis; but, failing all these things, the 
child will probably do well. 

Treatment. — " The only certain cure for infantile syphilis 
is mercury," writes Henoch ; and probably in that short 
summary lies the kernel of the experience of all. The mer- 
curial may be administered either by giving it to the mother 
(a plan which has been advocated strongly by some, but 
which is too uncertain), by internal administration, or by 
inunction. 

Nothing need be added to the statement of Dr. Eustace 
Smith, that in the hydrargyrum c. creta, or the liquor hy- 
drargyri perchloridi,* we have two effective and easily borne 
preparations. The former may be given in grain doses night 
and morning, with two or three grains of bicarbonate of 
sodium or bismuth ; and .this dose may, if necessary, be 
increased to two grains of the mercurial. In case of diar- 
rhoea, the solution of the perchloride may be given ; infants 
take it well in one-quarter to one-half-drachm doses, which 
may be gradually increased if necessary. 

The inunction is carried out by rubbing half a drachm of 
mercurial ointment upon the abdomen, back, or sides, and 
covering the part with a flannel roller afterward. The child 
should be well bathed every morning with soap and warm 
water, before the daily inunction is made. 

Besides specific treatment of this kind, attention must be 
given to all those more general means which will ensure the 
preservation of the child's health. Its food must be attended 
to, and it should of course be suckled by the mother, if pos- 

* This contains one-half grain of the bi-chloride to the fluidounce. 



428 DISEASES OF CHILDREN. 

sible. But here may come a difficulty. Supposing that she 
should show no signs of disease, is the child to be weaned 
for fear of contaminating her ? This is a question that can- 
not be answered by a yes or no. It is held by some that 
the ovum can be infected through the father, and be born 
syphilitic, the mother all the while remaining intact. If that 
be the case, the answer must be yes. But, on the other hand, 
there is a strong a priori improbability of any such freedom 
being possible ; and there is also the fact, vouched for by 
many observers, that the infant thus syphilized in utero never 
contaminates the mother by suckling, although she may 
show no signs of having already been syphilized. If this be 
so, the answer will be no ; for the fact is inexplicable, except 
on the hypothesis that the mother is already proof in some 
way against infection, and this is certainly much the more 
probable belief. It is almost inconceivable that a fcetus 
should lie in utero for many months, receiving from, and 
returning a constant blood supply to, the mother, without 
conveying the disease from which it is suffering, and which 
is known to be so easily inoculable. On the other hand, it 
is in consonance with all we know of infective disease that 
the mode of introduction of the poison may lead to such 
modification of the disease as may render it more or less 
incapable of recognition. On the whole, therefore, it is 
probable that a mother who bears a syphilitic infant is proof 
against contagion, and may suckle her child if it be consid- 
ered advisable, as, in most cases, it certainly will be. As a 
first thought, therefore, for the safety of the child, the 
mother's health must be attended to. Not at all improb- 
ably a little of the liquor hydrarg. perchlor. or some iodide 
of potassium may better her condition, and, while acting 
upon her, act upon the child through the medium of the 
milk ; but all other means for improving her health, in the 
way of good food, fresh air, etc., must be adopted as well. 






INFANTILE SYPHILIS. 429 

If the mother be unable to suckle her child, then artifi- 
cial human milk or goats' milk or asses' milk are the best 
substitutes; but the introductory chapter will supply all 
information on this head. 

Wasting, diarrhoea and vomiting require the same kind 
of treatment that they receive under other circumstances. 

Of the local conditions, the enlargement of the liver will 
often readily subside under mercurial treatment. That of 
the spleen is much more troublesome, and its continuance 
is no warrant for the prolonged administration of mercury 
if all other signs of the disease are in abeyance. In the 
pneumonia and the bone disease of the syphilitic infant the 
specific must be continued, in the one case with stimulants 
such as carbonate of ammonium or alcohol, in the other 
with iron and cod-liver oil. The pneumonia is fortunately 
rare ; but neither complication responds quickly to reme- 
dies, and a case of either kind, except where the bone 
disease is confined to the production of a natiform skull — 
which does not much influence the prognosis — must be 
treated as of doubtful issue. 

A large number of the troubles of infantile syphilis are 
shown upon the skin. Condylomata are perhaps the most 
common. The parts are to be kept scrupulously clean by 
frequent bathing and change of linen, remembering that 
syphilis is always ready to pounce upon seats of local in- 
flammation ; cracks, fissures, excoriations of any kind, are 
likely to lead on to ulceration or condylomata. Condylo- 
mata are to be kept as dry as possible, and dusted with 
calomel night and morning. The calomel may be used 
pure, or mixed with an equal part of oxide of zinc. 

The same treatment may be adopted for the small patches 
which occur at the angles of the mouth. 

In the dry eruptions nothing is generally needed but the 
internal treatment. For such patches as are intractable, the 



430 DISEASES OF CHILDREN. 

mercurial ointment may be applied, or a dilute solution of 
the oleate of mercury — the 5 per cent, strength diluted with 
three parts of carbolic oil, strength 1 to 40. For the ecthy- 
matous sores that form over the trunk and extremities, and 
about the nails, the ung. hydrarg. oxid. rub. is as good as 
anything, and for some of these cases a mercurial bath may 
be given twice a week. Dr. Eustace Smith recommends 
that half a drachm of the perchloride of mercury should 
be dissolved in each bath. After the more definite symp- 
toms have subsided, the child will usually require a pro- 
longed course of iodide of iron and cod-liver oil, not only 
with the object of keeping up its strength, but to ensure, if 
possible, a freedom from chronic disease of bone, ozaena, 
and such things as go under the general term of struma, 
and which blight the happiness, not only of the child, but 
of many a family also. 



PART V. 

DISEASES OF THE SPLEEN AND 
BLOOD. 



i. Diseases of the Spleen. — Diseases of the spleen are 
only to be recognized clinically by pallor — which sometimes 
possesses a peculiar tint — and by an enlargement of the 
organ. A diseased spleen is usually an enlarged spleen, 
and therefore few cases should escape notice. 

Causes. — Splenic enlargement is a very common affection 
in children, and is generally due to one or other of the follow- 
ing conditions — rickets, syphilis, ague, tubercle, typhoid 
fever; or its cause may be undiscoverable. Having said this, 
the student is in possession of the more common causes of 
splenic disease. The enlargement of leucocythaemia occurs 
occasionally. Some increase of size and alteration of struc- 
ture is sometimes found with Hodgkin's disease ; lardaceous 
disease is common in children, and cirrhosis' of the liver 
may occasionally be associated with some splenic swelling ; 
but in all these the one change, being coupled with others 
which have general symptoms of more prominent kind, is 
of less importance, and the description of the same form of 
disease in the adult will apply to that in the child. The 
symptoms of lardaceous disease, of Hodgkin's disease, of 
cirrhosis of the liver, are all sufficiently distinctive. In the 
affections enumerated above the spleen may be the only 
part to attract attention, over and above the pallor that 

431 



432 DISEASES OF CHILDREN. 

exists. As regards the frequency of the various forms of 
enlargement, of seventy-four cases of which Dr. Goodhart has 
notes, twenty were associated with well-marked rickets ; in 
twenty-four others the rickets was very little indeed, or none 
at all, and the disease could not in these cases be with 
certainty attributed to this or indeed any other cause — some 
may have been due to pulmonary obstruction, some, perhaps 
to ague ; fourteen were in syphilitic children ; in ten it was 
a part of a general tuberculosis. Of the remainder, two 
were febrile cases, three leukemic, and one the result of 
ague. The enlargement which is due to typhoid fever has 
so brief a mention because its finds its appropriate place 
under the disease to which it belongs. 

Morbid Anatomy. — Rachitic and simple chronic enlarge- 
ments usually show similar appearances. The spleen is 
large, its capsule perhaps a little thick, its substance firm, 
pale or dark-colored, and under the microscope the fibrous 
septa of the organ are thickened. Dickinson has made a 
valuable contribution to the histology of the rachitic spleen, 
and considers the disease to be a fibrosis. Goodhart has 
seen hyaline thickenings of the septa that might be called 
fibrotic in four cases which he has examined. As is well 
known, an albuminoid change has been described by Jenner 
as peculiar to rickets, but this can only occur in the more 
extreme cases, and it is decidedly uncommon. Goodhart 
has never seen it, and Dr. Gee only occasionally. 

There is hardly enough evidence at hand to prove what 
are the precise changes which a syphilitic spleen undergoes, 
but its coarse appearances are usually such as are seen in 
simple chronic enlargement. The tubercular spleen has, 
scattered over the surface of its capsule, many large, juicy- 
looking, gray miliary tubercles; and similar bodies are 
spread thickly through its substance. Either on the cap- 
sule or in its substance, but particularly the latter, the 



DISEASES OF THE SPLEEN. 433 

tubercles are often caseous and appear as small yellow 
grains. 

Symptoms. — Enlargement of the spleen goes almost con- 
stantly with pallor, which is sometimes peculiar in the depth 
of its sallowness and sometimes in the tint being slightly 
brownish or green. 

Diagnosis. — There are no special points about the dif- 
ferent diseases which enable one to distinguish one form of 
enlargement from others. The various causes enumerated 
must be kept in mind, and other symptoms of the special 
disease examined ,for. In the two diseases which are so 
difficult to distinguish from one another, typhoid fever and 
acute tuberculosis, the spleen of the one can sometimes be 
distinguished as soft, and that of the other as hard. It may 
also be said that the tubercular and the syphilitic spleen are 
both more often associated with enlargement of the liver 
than are rachitic and simple chronic enlargement of the 
organ. 

The blood is usually very abnormal in these cases. The 
author has made a large number of examinations, and the 
conditions are fairly constant. The blood is wanting in 
haemoglobin — sometimes as much as sixty per cent, being 
absent, if measured by the haemoglobinometer. The red 
corpuscles are diminished — it may be as much as three- 
fifths of the whole — and a moderate excess of colorless 
corpuscles occupies each field of the microscope, some of 
them large, others much smaller than common. Various 
stages of development of the red corpuscles can also usu- 
ally be seen, to judge from the variety of size that may be 
met with ; these range from free granules up to the normal- 
sized red corpuscles. 

Prognosis. — All splenic enlargements are liable to prove 
intractable. Even those of syphilitic origin, which might 
be expected to answer readily to drugs, respond but tardily 



434 DISEASES OF CHILDREN. 

in comparison with the same conditions in other viscera. 
It is a common thing to find the liver decreasing rapidly in 
size, while the spleen has altered but little. As a rule, they 
slowly improve in the course of months. The author has 
known one or two cases to waste steadily and to die — no 
cause, rachitic or other, being found post-mortem to ex- 
plain death, except the enlargement of the spleen. 

Treatment. — The spleen of ague or of syphilis will require 
the remedies appropriate to those diseases. All forms, asso- 
ciated as they are with pallor, will require careful blood 
restoring, either by arsenic, iron, cod-liver oil or sea air. 

The rachitic and the chronically enlarged spleen do best 
upon beef juice or raw meat, and the syrup of the lacto- 
phosphate of iron in half-drachm doses ; a varied diet of 
good food and plenty of fresh air being supplied meantime. 

One may venture to suspect, from the slow progress of 
all cases of enlargement of the spleen, that, given a certain 
duration of the morbid condition, changes take place in the 
circulation through the organ which make a rapid return to 
normal impossible, and it therefore seems advisable to resort 
to external aid, such as gentle friction over the surface of 
the organ by oil or soap liniment, in addition to other means, 
for, although no striking success can be hoped for, some 
may possibly be achieved. 

2. Purpura. — This condition is by no means uncommon 
in children of the lower classes as the result of bad feeding 
or bad living. It may be met with in all degrees, from 
scattered petechise in the skin, of small size, and which 
might easily be mistaken for flea-bites, or larger and more 
profusely spread, up to considerable extravasations into the 
subcutaneous tissue, or to bleeding from the nose, gums, 
stomach, bowels, and kidney. Purpura when confined to 
the skin is sometimes called simple; when affecting mucous 
membranes also, purpura hemorrhagica, or morbus macu- 



purpura. 435 

losus. Purpura is a condition which is found associated 
with many diseases, such as rickets, rheumatism, blood- 
poisoning of various septic kinds, or ulcerative forms of 
heart disease, and it is produced in some subjects artificially 
by the administration of drugs, such as iodide of potassium. 
Many of these forms, however, are allocated to the distinct 
disease, and we have thus purpura rheumatica, the petechiae 
of scarlatina and smallpox, and the purpura of heart dis- 
ease. These are not generally included in the term pur- 
pura, but only such cases as originate, often without fever, 
without any more definite cause than prolonged failure in 
nutrition, dietetic or other. Even extreme cases of this 
kind are not uncommon, and they usually speedily get well 
upon proper diet. Dr. Goodhart, however, has met with 
one case which was associated with fever and severe intes- 
tinal lesions, which speedily proved fatal. The intestine 
was found in this case in a spongy, tufted condition, not 
unlike the gums as seen in bad cases of scurvy. 

Hemorrhage occasionally occurs about the fundus oculi 
in purpura. This lesion has of late been frequently de- 
scribed ; but it probably has no special importance attach- 
ing to it. A girl, aet. four, was admitted to Dr. Goodhart's 
wards on July 31st, 1877. She had been languid and fret- 
ful, suffering from stomatitis for three days, and two days 
before admission the body became covered with purple 
spots. The gums commenced to bleed on the morning of 
admission, and blood had also come from the right ear, 
from which for two years there had been an occasional 
discharge of pus. The child by nature was of a dark, 
sallow complexion, but had enjoyed good health. It had 
been noticed that since her birth any scratch or cut would 
bleed freely. The child had been well fed, was fond of 
vegetables, and had had plenty. The mother was of dark 
complexion, and believed that she had had a similar attack 



436 DISEASES OF CHILDREN. 

when a child. The gums were much swollen, grayish- 
looking, and fungating. All parts of the body were covered 
with small petechias but no bruises. The child lay feeble 
and exhausted, with a temperature of 99.8 , pulse 134, 
respiration 20. The urine was normal. The thoracic and 
abdominal viscera also. Gallic acid, in six-grain doses, was 
administered three times daily, and green vegetables, milk, 
and beef-tea were ordered. The bleeding from the gums 
becoming serious, they were painted with tincture of per- 
chloride of iron. She vomited blood twice only ; passed 
none in the evacuations and none in the urine. The 
bleeding from the gums gradually ceased, and the spots 
faded from the skin, and she left the hospital well after 
about three weeks' stay. 

During her illness the fundus oculi was examined for 
hemorrhage, and on the right side, above and internal to 
the optic disc, and at some distance from its margin, a large 
dark round blotch was seen, with a haze over it, and a white 
margin surrounding it. Near it was a large vessel. The 
appearances were those of hemorrhage into the choroid, 
with either atrophy around it or the white margin of a dis- 
placed retina. Both discs were whitish, and the choroidal 
pigment was very unevenly distributed — some parts of the 
choroid looking white by contrast with others. 

The child was seen again some months later, and, the 
pupils being dilated with atropine, the fundus was fully ex- 
amined. No trace of the former hemorrhage existed, and 
the uneven distribution of pigment so marked before was 
now hardly noticeable. 

Seven cases of purpura that have been under the author's 
care in the Evelina Hospital have all been of the female sex. 

Of the pathology of purpura nothing is known ; the blood 
has been examined, without result ; the bloodvessels also, 
with no decided bearing. All that is known is the prac- 



HAEMOPHILIA. 437 

tical fact that it depends often upon deprivation of particu- 
lar kinds of food, and quickly disappears when these are 
supplied. 

It is indeed but seldom fatal, except it be associated with 
high fever; in severe cases, however, the amount of bleed- 
ing from the nose, the bowels, or the kidney, may give rise 
to some anxiety. 

Treatment. — Rest in bed is necessary if the attack be 
severe ; and to stay the bleeding some gallic acid may be 
given in honey, or some turpentine in syrup ; possibly the 
tincture of hamamelis maybe useful. The body should be 
kept cool, and ice may be applied if necessary, to the head 
or spine, or even placed in the rectum. Plenty of good 
milk should be given, and orange, lemon, or lime-juice, 
with green vegetable diet and underdone meat or beef juice. 

3. Haemophilia. — Purpura — the just detailed case in 
particular — with its history of a tendency to bleed to excess 
on slight scratches, etc., leads naturally to the considera- 
tion of haemophilia, or the hemorrhagic diathesis. This is 
a disease which is strongly hereditary, and is far more 
common in males than in females, the proportion being 
about eleven to one. As regards its transmission, there is 
this curious fact, that it passes to the males through the 
females, the mothers remaining quite healthy while passing 
on the disease to their sons, and fathers who are bleeders 
but rarely transmitting it to their sons. The females in 
bleeder families, according to Dr. Wickham Legg, from 
whom this account is borrowed, are, unfortunately, remark- 
ably fertile. 

Symptoms. — The subjects of haemophilia differ in no ap- 
preciable respect from other people. They are generally 
healthy. The symptoms usually show themselves soon 
after birth, within the first year or two of life, and are char- 
acterized either by bleeding from the nose or mouth or 
37 



43 8 DISEASES OF CHILDREN. 

spontaneous ecchymoses in the skin. In the extreme cases, 
found usually only in the males, the bleeding arises spon- 
taneously, or from the most trivial causes, and occurs not 
only in the skin and from mucous surfaces, but large ex- 
travasations take place into the subcutaneous tissue and in- 
termuscular septa, and into the cavities of the larger joints. 
To this escape of blood into the joints is due the obstinate 
swellings of the joints, particularly of the knee, which char- 
acterize this disease. 

Of the few cases that have come under Dr. Goodhart's 
notice, one was a boy, aged four, who had persistent epis- 
taxis after some slight injury. Another, a boy, aged nine, 
with epistaxis to blanching, whose brother suffers also from 
frequent epistaxis. A third, a male, of eighteen months, he 
is uncertain about, from the possible existence of rickets. 
He had had convulsions, and his head was large ; but he 
looked in perfect health, except that he was covered with 
painless lumps, of bruise-like appearance. In some of these 
the amount of extravasated blood was large. The whole 
body was dotted over with petechiae. One sister had passed 
blood per anum, and had been in Guy's Hospital for haema- 
turia. And another boy, who died aged twelve, was said 
also to have had lumps much like those of this child. A 
fourth, a boy, aged five, bled profusely after the extraction 
of a tooth. Several others in the same family had suffered 
from the same thing, and there was a married sister who 
always lost severely at her confinements, and whose cata- 
menial flow lasted a fortnight out of every month. 

Pathology. — Nothing is known of the cause of this con- 
dition. The various viscera have been examined, and the 
blood also, but mostly without result. 

Diagnosis. — This is not easy from purpura due to other 
causes. Attention must be paid to the personal and family 
history and to the sex of the patient. 



scurvy. 439 

Prognosis. — The disease appears to be persistent through- 
out life, and there is naturally a risk to life from the occur- 
rence of profuse hemorrhage at any time. Nevertheless, if 
all due care be taken to avoid injury, the extraction of teeth, 
etc., and to keep in as good a state of health as possible, 
there is no reason why old age should not be attained. As 
regards the local affection of the joints, it is slow to depart, 
and is often associated with pain and fever. 

Treatment. — The perchloride of iron appears to be the 
best remedy, though none can be said to materially influence 
the. disease. Preventive treatment is the more effective — viz., 
the avoidance of injury in any shape, warm clothes, resi- 
dence in a warm climate, and good living. When hemor- 
rhage has been so severe as to threaten life, transfusion 
may be resorted to. The joint affection must be treated 
upon general surgical principles, by rest, splints, etc., 
bearing in mind that the fluid within is blood, and there- 
fore that, after the inflammation has subsided, gentle move- 
ment of the joint is advisable, to prevent the formation 
of adhesions. 

4. Scurvy is not strictly a disease of childhood ; but, of 
late, attention has been called to a scorbutic affection of the 
bones, often associated with moderate rachitic changes, and 
which has hitherto passed as " acute rickets," chiefly from 
the descriptions given of it by foreign writers who had no 
knowledge of its morbid anatomy. Dr. Cheadle,from cases 
which have come under his own care, propounded the 
doctrine that the disease was a compound of rickets and 
scurvy. Gee has published cases evidently of the same kind 
under the name of " osteal or periosteal cachexia ; "* and 
Barlow, in the Medico- Cliimrgical Transactions^ has con- 

* St. Bartholomew's Hospiial Reports, vol. XVII, p. 9. 
f Vol. lxvi, p. 159. 



440 DISEASES OF CHILDREN. 

siderably extended our knowledge of the subject by eleven 
additional cases, two of which are of the greatest value, for 
the writer was able, by a post-mortem examination, to 
demonstrate the actual nature of the lesion that existed. 
From these two cases, and another already published in the 
Transactions of the Pathological Society of London, by Mr. 
Thomas Smith, it is shown that the clinical features of acute 
rickets are associated, it is true, with moderate rachitic 
changes, but much more with extensive sub-periosteal 
hemorrhage in the bones, chiefly the femora and tibiae, 
scapulae, ribs, and cranium, and with a tendency to fracture, 
and sometimes with separation of the shaft from the 
epiphysis, as occurs in syphilis, acute necrosis, and perhaps 
also in other conditions. 

The clinical symptoms are given in the following case, 
which was sent the author by Mr. Oram, of Clapham, and 
the nature of which he at once recognized, being fresh from 
the perusal of Dr. Barlow's paper : — 

A child of fifteen months. Its father is a dark man, and, 
Mr. Oram states, one of the most anaemic men he has ever 
seen. The mother is slim and small, but calls herself healthy. 
There is no rheumatic history. This is her first child. She 
nursed it for four months, and since then it has been fed on 
" milk food." " The child cannot take milk." For many 
weeks it has been subject to effusions of blood in the cellu- 
lar tissue of the orbits. The effusion takes place .quite sud- 
denly, and perhaps before it is reabsorbed a fresh one occurs. 
For a month or two it has been quite unable to move its 
limbs. It was not an anaemic child in any marked degree. 
Its head was rather rachitic, the anterior fontanelle open ; no 
craniotabes ; no bosses on the skull. The two lower incisors 
only were cut; the gums were normal; no purpura. Both 
upper eyelids were swollen out by large effusions of blood, 
giving a black eye on each side, and the left eye was promi- 



scurvy. 44 1 

nent in addition, apparently from effusion of blood into the 
orbit. 

The child shrieked most painfully whenever it was 
touched, so that there was much difficulty in ascertaining 
where the most pain lay, but it was chiefly in the lower 
limbs. The radial ends were nodular, the ribs moderately 
beaded ; the thighs and spine normal ; the knees also. 
The lower half of each leg was swollen, brawny-looking 
and indurated ; the dorsum of the foot was cedematous ; the 
skin was pale and without any undue heat. It was impos- 
sible to be quite certain of any thickening of the bones, 
as the child's shrieks were terrible directly its legs were 
handled; but the indurated feeling of the integuments, and 
their peculiar adhesion to the bone, not unlike the sensation 
of scleroderma, made me think that the bones were affected. 
The optic discs were healthy ; the urine was not examined ; 
the liver and spleen were normal. 

Raw beef juice was ordered, underdone pounded meat, 
orange juice, and milk — the diet to be varied as much as 
possible — and opium was given in small doses three times a 
day. The child rapidly improved ; and a month later it was 
free from pain, took its bath with pleasure, and moved its 
legs freely. 

This case corresponds in all essentials with those that 
have been described by others, and with four others which 
have lately came under the author's own notice. There 
was plenty of evidence of a moderate degree of rickets ; 
but the brawny tension of the lower limbs from the ankle 
upward, and the extreme pain, were as certainly something 
more than rickets, and corresponded with what has been 
observed by Barlow to be associated with sub-periosteal 
hemorrhage. Then there was the fact that it was supposed 
not to be able to take milk, and its diet had been nearly 
confined to artificial food ; at the same time there was no 



44 2 DISEASES OF CHILDREN. 

evidence of syphilis ; the parents were moderately well-to- 
do ; and the child rapidly improved by a simple change of 
diet, and by quieting its pain by the temporary administra- 
tion of opium. 

Diagnosis. — It is, perhaps, most likely to be mistaken for 
syphilitic disease of the bones. This, as is well known, is 
liable to occur at the epiphysial junction, and to spread as a 
periostitis along the shaft of the bone, and leads to abscess 
and to separation of epiphysis from shaft. The absence of 
any definite signs of syphilis, and the existence of rickets, 
with the history of bad feeding, might in most cases make 
us suspect the real nature of the affection ; but it may be 
also added that the brawny induration running gradually 
up the shaft is not quite what is met with in syphilis, nor 
is the extreme pain of these cases often found to such an 
extent in the syphilitic bone disease of infancy. Moreover, 
as Barlow points out, syphilitic disease occurs at an earlier 
age than does acute rickets. 

Prognosis. — If treated properly, and not already too ex- 
hausted, these cases will get well, though the process ot 
recovery is sometimes tedious. 

Treatment. — This resolves itself into variety in diet — 
such things as raw beef-juice, underdone pounded meat, 
orange juice, cauliflower, julienne, or milk, etc., being par- 
ticularly useful. In all the cases seen by Dr. Goodhart he 
has advised the administration of small doses of opium, 
sufficient to relieve the pain, with decided benefit; and after 
a little while some chemical food or cod-liver oil should be 
given to relieve the anaemia. 

5. Anaemia is a very common ailment in childhood. 
Naturally, both bad blood and poor blood are associated 
with all sorts of diseases, and are, in fact, among the 
symptoms of many; but besides these morbid states of the 
blood, due to definite disturbances and changes in the 



ANEMIA. 443 

viscera, it is no uncommon thing to find that a child is 
anaemic, and without definite cause for it. The child may 
have been working hard, or playing hard, or growing fast, 
or the pallor may be the remnant of some preceding 
illness ; but whatever may be given as the explanation, 
the most careful examination fails to show any organic 
disease. 

Anaemia is common to all ages, from infants a few months 
old and upward ; and in younger children, from babyhood 
up to three years, it is often, but not always, associated 
with some enlargement of the spleen ; often with constipa- 
tion. 

The microscope usually shows a very abnormal state of 
blood in these cases : the red corpuscles are much dimin- 
ished in number; the white corpuscles are in slight excess ; 
a number of small corpuscles stud the field, and there is 
also more or less granular matter. 

Diagnosis. — This must only be arrived at by a careful 
exclusion of every other disease. The child must be 
thoroughly examined ; and only in the absence of actual 
structural changes in the viscera, in the absence of syphilis 
and ague, or rickets, is simple anaemia to be diagnosed. 

Prognosis. — Simple anaemia is sometimes very intractable, 
and one cannot but feel that, in such cases, the condition is 
a serious one. It is impossible that the blood can be seri- 
ously at fault for any length of time during the period of 
growth and development without harm. The difficulty that 
exists of gauging its exact influence upon this organ and 
on that does not make the risk any the less, and an anaemic 
child requires attentive care. 

Treatment. — The difficulty lies in getting at what is 
wrong ; too often it is considered sufficient to give a tonic, 
chiefly iron, and this almost without inquiry. But, before 
resorting to drugs, investigation must be made of the per- 



444 DISEASES OF CHILDREN. 

sonal hygiene of the child — its disposition, its food, its sleep, 
its clothes, its habits, its play, its work, its home, and its 
environs, etc. Not till all these things have been considered 
can it be determined whether the requisite treatment should 
be by aperients, by quinine, iron, arsenic, or cod-liver oil, 
or by more food, more air, less work, and so on. If careful 
inquiry be given to these matters, the treatment will gen- 
erally suggest itself. 



PART VI. 



DISEASES OF THE NERVOUS SYSTEM. 

i. Inflammation of the Dura Arachnoid is dependent, 
as in adults, upon injury or disease of the bones of the 
skull. It is comparatively rare, and causes no special 
symptoms other than will be considered as those of menin- 
gitis. Meningitis is, indeed, usually associated with it; and 
one hardly meets with those more chronic forms of disease, 
or pachymeningitis, that are met with in adults. As a rare 
instance, however, of something of the kind, the first of 
the cases which follow may be given. The second case, 
while it illustrates the occurrence of local collections of pus 
in the arachnoid, also shows the liability which exists for a 
general meningitis to be set up under those circumstances. 

A boy, aged four and a half, was admitted under Mr. 
Birkett in 1874, for a swelling in each upper eyelid. Twelve 
months before his admission his left eye began to swell; a 
•nonth later the other eye did the same, and for three weeks 
before admission he had been very drowsy. He was admitted 
for the tumor over the left orbit, and it was then noticed that 
there was a hard cartilaginous body, freely movable under 
the skin, beneath the margin of the left orbit. His sight was 
unaffected, and the movements of the eyeball were perfect. 
His temperature ran up to 104 and 105 ° within a day or 
two of admission, and he died of pyaemia. 

At the autopsy, tlie history of the case appeared to be 
this : There had been caries of the first lower molar and 
38 445 



446 DISEASES OF CHILDREN. 

abscess ; then suppuration in the inferior dental canal, acute 
ostitis of the left side of the lower jaw, extension of the dis- 
ease in the pterygo-maxillary fossa, and thence to the base 
of the skull. Having entered the skull by the foramina at 
its base, and having thickened and dissected up the dura 
mater from the base of the skull in the middle fossa and 
about the body of the sphenoid bone, it had entered each 
orbit, treated the periosteum of those cavities in like man- 
ner, and the tumor in the left orbit was in reality only a 
tough yellow mass, of inflammatory origin. 

A female child of six months was brought for wasting of 
three weeks' duration. She was emaciated and pale, the 
veins of the head were distended, and the fontanelle, 1 )/ 2 
X lyi inches, was bulging and pulsating. There is no 
note of any paralysis, but there were soft, elastic, tender 
thickenings over the lower halves of the right radius and 
ulna and left humerus, a state of things which, at this dis- 
tance of time (nine years), sounds very like syphilitic 
disease of the bones, though it does not appear to have 
occurred to any of those who saw the case, myself among 
the number, to call it so. The child died with convulsions. 

At the autopsy, a large collection of pus was found 
between the dura mater and the right side of the brain. 
It extended from vertex to base, and from the anterior 
part of the middle fossa back to the horizontal branch o^ 
the lateral sinus. It did not enter the cerebellar fossa. 
Its wall was ochre-yellow, like a typhoid stool, but the pus 
itself was " laudable." Pus occupied the ventricles. The 
lateral sinus was plugged on both sides, the left by clot of 
older date than the right. There was no disease of the 
internal ear. The bones were slightly rickety. 

A condition such as this is probably more often produced 
by disease of the bones of the ear, or of the petrous bone 
or mastoid cells as a consequence thereof, and careful 



SIMPLE MENINGITIS. 447 

search for such should be made at the post-mortem exami- 
nation ; but it may occur from pyaemic conditions, from the 
extension inward of erysipelas, or from unhealthy inflam- 
mation of the bones of the scalp and of the pericranium, 
and occasionally, also, in the absence of all but emaciation, 
the disease may have originated spontaneously. 

Intra-arachnoid hemorrhage and pachymeningitis have 
been described by most writers, but such conditions are of 
rare occurrence, and are not peculiar to childhood ; they 
will not therefore be further mentioned here. 

Attention must, however, be called to the fact that, in 
young children, pressure upon the surface of the brain, 
whether by hemorrhage or pus, as illustrated by the cases 
of arachnitis already recorded, seems less liable to cause 
paralysis than might have been imagined. Surface hemor- 
rhage or pressure is more likely to produce stupor with 
feeble circulation and death either by convulsions or ex- 
haustion, and this is a point of importance in diagnosis. 

2. Simple Meningitis (Lepto-meningitis, suppurative 
meningitis) is probably a disease which is more common 
than has been supposed. Tubercular meningitis is more 
so, but there has been too great a tendency to sweep all 
forms of meningitis of childhood into the net of tubercle 
than is justified by the facts of post-mortem examination. 
The author has notes of forty-one post-mortems of cases 
which without an examination would have been set down 
as tubercular, but eight of them, or one-fifth, were simple ; 
and in a most valuable paper by Drs. Gee and Barlow, in 
the " St. Bartholomew's Hospital Reports" for 1878, " On 
the Cervical Opisthotonos of Infants," six cases are given, 
in which a post-mortem demonstrated the absence of tuber- 
cle and the presence of simple basal meningitis. Cause for 
acute meningitis is to be found abundantly in disease of the 
ear and nose, and in the acute exanthems and many other 



44-8 DISEASES OF CHILDREN. 

febrile states that are met with at this time of life. Simple 
meningitis is said to be developed by preference at the 
convexity, and has therefore been called by some meningitis 
of the convexity ; but a non-tubercular basal meningitis is 
far from uncommon, and the fact that the convexity is also 
often attacked is probably due to the disease being so often 
an extension from disease elsewhere — or secondary, as it is 
called — but even then it is liable to extend all over the 
surface and even into the ventricles. The brain is usually 
covered with a layer of yellowish or green pus, and the 
same kind of material may be found in the ventricles, and, 
if the case be in any degree prolonged, the lining membrane 
of the ventricles may be of a rose-pink color from minute 
injection, and villous-looking or velvety from inflammation. 
The pus may also be found to extend down the cord in 
quantity, where it will mostly appear on the posterior aspect, 
having evidently gravitated to that position. There is no 
distinction, such as is sometimes made between meningitis 
of the brain and that of the cord. The membrane affected 
is one and the same, and disease of the membranes of the 
brain runs with perfect facility along those of the cord. In 
some cases the inflammation appears to be shut off about 
the foramen magnum, but this is probably rather an acci- 
dent than anything else. 

Simple meningitis appears to be a disease of infancy rather 
than of childhood, but associated with otitis of the middle 
ear, it is not uncommon at any time of life. 

Symptoms. — These are often indefinite, although the 
course of the disease may be rapid ; and if we may accept 
cervical opisthotonos as evidence of meningitis, it may not 
only be very chronic but even remittent. The child is pale, 
with retracted head and much screaming if moved ; its 
abdomen is retracted, the bowels confined, and it takes food 
badly. There may be fever, rigidity of limbs, convulsions, 



SIMPLE MENINGITIS. 449 

vomiting, and, in very chronic cases, hydrocephalus. The 
symptoms appear to depend somewhat on the age of the 
child — in infants a tendency to collapse may be noted, with 
markedly oscillating temperature, with restlessness, swelling 
of the head, enlargement of the veins of the surface, and 
retraction of the neck; in older children there is more fever, 
and definite evidence of meningitis, in headache, vomiting, 
irregularity of pulse, and squint. 

The disease is met with after injury — otitis (externa or 
media), ozaena, excessive mental effort in children at school ; 
it may occur also after some acute illness, such as scarlatina, 
erysipelas, or nephritis, and it has been noticed as one of the 
results of the pyaemic condition found in new-born children 
from inflammation about the umbilical sore. Of the two 
cases which follow, one exemplifies the occurrence of menin- 
gitis after injury; the other after otitis interna. 

A previously healthy male child, aged seven months. 
The mother fell with it in her arms a fortnight before it was 
brought to the hospital. Ever since then it had held its 
head back, screamed much at any attempt to move it for- 
ward, and the head had swelled considerably. It had not 
vomited. Its bowels were confined ; it had a sallow pallor ; 
its temperature was normal ; the pulse quick, but regular ; 
and the neck retracted. There was no rigidity of limb. It 
lay nearly insensible, with retracted pupils, retracted abdo- 
men, and in a collapsed state ; the tongue being furred and 
dry, and no food being taken. It died shortly afterwards. 

At the autopsy, the viscera were all healthy, except the 
brain. The latter was congested, dry on the Surface, and 
the convolutions pressed together. A little pus-like lymph 
was found at the base, and here and there on the convexity. 
The ventricles contained seven or eight ounces of turbid 
sero-purulent fluid, and they were widely dilated. Their 



450 DISEASES OF CHILDREN. 

ependyma was thick, woolly, velvety, and patched with pur- 
ulent lymph. In the posterior cornu of the left ventricle 
was a local collection of fSiij or pure pus. The brain was 
soft ; the cord normal ; rather adherent at the foramen mag- 
num. There was no disease of ears or sinuses ; and, so far 
as could be detected, nothing whatever to account for the 
disease but the blow received some weeks before death. 

A girl of seven had been ailing for a month, and deaf in 
the right ear ; there had been no discharge. Subsequently 
there was high temperature, retracted neck, and strabismus. 

The autopsy showed general suppurative meningitis, sup- 
puration of the middle ear, on both sides, extending to the 
bone, and points of pus appearing on the internal table in 
many places. The membrana tympani was sound on both 
sides. Dr. Goodhart subsequently traced the suppuration 
along the. bony part of the Eustachian tubes. There was 
chronic enlargement of one tonsil. 

Diagnosis. — This will in most cases be difficult. In young 
children the symptoms of meningitis are often obscure, and 
marked by an abscess of those most characteristic; but 
when the diagnosis of meningitis is arrived at, there comes 
the further question, is it tubercular or not ? 

The author has known two of the most distinguished and 
experienced physicians differ as regards the nature of a case 
of meningitis — one thinking it tubercular, the other not. 
The case in question turned out to be non-tubercular ; but 
the reason of the successful diagnosis it would be hard to 
give. 

Barthes and Sanne give a table of distinctions, which, in 
short, amount to these : — 



SIMPLE MENINGITIS. 45 I 

Simple Meningitis. Tubercular. 

1. Occurs in healthy children of I. The reverse of this, 
good family history. 

2. The disease may be epidemic. 2. Always sporadic. 

3. The attack is sudden, in the 3. The disease makes headway 
midst of health or after well marked insidiously. 

non-tubercular ailment. 

4. Onset by violent convulsions, in- 4. Never convulsions at onset, 
tense fever, headache, vomiting. Passage of the prodromal into the 

acute stage sometimes indistinguish- 
able. 

5. Symptoms all intense, except con- 5. Vomiting of late onset, obsti- 
stipation. Headache, vomiting, violent nate constipation, tranquil delirium, 
delirium or coma, fever. little fever. 

6. March rapid ; duration short. 6. The reverse of this. 

In infants retraction of the neck should excite attention, 
and any rigidity of the neck or pain on movement. The 
other signs of meningitis must then be carefully sought, such 
as rigidity of the muscles elsewhere, evidence of pain in the 
head, swelling of the head, distention of the veins of the 
scalp, vomiting, retraction of the abdomen, constipation, 
irregularity of pulse, a tendency to reddening of the skin 
upon slight irritation (taclie cerebrale), and the state of the 
fundus oculi. 

In all children the previous health must be taken into 
account — the preexistence of measles, scarlatina, sore throat, 
earache, and so on ; the existence also of pyrexia, intoler- 
ance of light, headache, etc., may, any one of them, help 
on occasion. 

In meningitis there is no symptom which is infallible ; 
there are no two or three which will not sometimes play us 
false ; but the most reliable are, retracted head, fever, cause- 
less vomiting, irregularity of the pulse, retraction of the 
abdomen, and muscular rigidity, or weakness. A child of 
two years, lately in Guy's Hospital, well illustrated the 
difficulties which beset the diagnosis of meningitis. He 



452 DISEASES OF CHILDREN. 

had had a discharge from the left ear for some weeks, but 
this had ceased a fortnight before his admission, and coin- 
cidently he had become stupid, with occasional vomiting 
and pain in the head. He was admitted with an irregular 
pulse, a markedly retracted abdomen, tache cerebrale, con- 
stipation and retracted neck. He was constantly mutter- 
ing, broken only by an occasional cry ; but he had a bright 
eye and did not suffer from intolerance. The vomiting did 
not recur after his admission ; but in other respects he 
remained in the same condition. The optic discs were per- 
haps a little cloudy. It became more and more difficult 
to feed him, and he ultimately died in a peculiar kind of a 
fit, of which he had previously had one or two, and in which 
he became blue and ceased to breathe. 

Dr. Goodhart confidently expected to find meningitis, but 
Dr. Carrington could find no disease of any kind except a 
little muco-pus in the left ear and a caseous gland or two 
in the mediastinum. 

On the other hand, pneumonia, by the acuteness of its 
onset and the violence of its delirium, may easily simulate 
meningitis, and so, also, may the noisy delirium tff typhoid 
fever. 

Otitis of the middle ear is supposed usually to spread 
from inflammatory affections of the fauces, and does so in 
some of the many catarrhal affections of this region. But 
it occurs often without any demonstrable source for its 
propagation, and it is not unlikely that it may originate 
spontaneously. As regards meningitis, the author has seen 
several cases where, the origin of the disease being obscure, 
attention has been very properly directed to the external 
ear, and no evidence whatever of the existence of any dis- 
ease could be obtained from that source, but in which, 
nevertheless, the tympanic cavity was shown to contain pus 
after death. The membrana tympani remains perfectly 



SIMPLE MENINGITIS. 453 

sound in these cases ; and Dr. Goodhart is afraid it must 
be said of this form of otitis that we have a (possibly fre- 
quent) source of meningitis, the existence of which cannot 
be determined during life. 

Prognosis. — This is very unfavorable; nevertheless, when 
we look over the notes of cases of hemiplegia, muscular 
rigidity and wasting, feeble intellect, apoplexy, and various 
other nervous disorders which occur in children, a fair pro- 
portion of these seem to originate in symptoms which cannot 
be distinguished from those of meningitis. Nay, more than 
this, scattered throughout hospital reports are notes of cases 
which have been considered to be meningitis, but in which 
that diagnosis has subsequently been rendered doubtful, or 
thrown over, because of the recovery of the patient. 

An impartial consideration of cases of this kind leaves 
very little doubt that the original diagnosis, at any rate in 
some, has been correct, and that what has really been the 
error has been the too rigid application of the more gen- 
eral rule that meningitis is generally fatal. 

No doubt some of the less severe cases of simple menin- 
gitis get <well. Dr. Goodhart refers to a case under the 
care of his colleague, Dr. Taylor, in which recovery might 
indeed never seem hopeless. For weeks a child of about 
two years old lay, apparently blind, with retracted neck, 
and to all appearance dying — its powers were so feeble and 
the nourishment taken so little; yet it lived on, and no 
doubt was of robuster material than given credit for, for 
a subsequent attack of scarlatina did not prove an extin- 
guisher, and now it is in good health. 

We must endeavor to extract our hope from any symp- 
toms which may suggest the localization of the mischief 
and the possible absence of suppuration. If the disease be 
of a purulent nature, from scarlatina or chronic disease of 
the ear, etc., recovery can hardly be expected. 



454 DISEASES OF CHILDREN. 

Treatment. — It is the fashion to give iodide of potassium 
in these cases, and, although it is seldom that any good 
results, yet, in the hope that some inflammatory material 
capable of absorption may be present, the practice may as 
well be continued. Small doses of calomel or hyd. c. cret. 
may be given as well. 

Counter-irritation and shaving the head are advised. Both 
are objectionable and apparently useless. An ice-cap to 
the head will do all that is necessary, although of this also 
it must be said that no great value can be demonstrated, 
nevertheless it should be used, and used vigorously and 
continuously. 

Quinine is another remedy which may be given if the 
temperature be high ; and in all those cases in which a pos- 
sible poison is at the bottom of the disease, it is well to 
remember that we may, in the future, and by careful trials, 
discover something which shall destroy it, and, therefore, 
new drugs of the germicide class deserve a careful trial 
when introduced. 

Any violent delirium must be controlled by bromide of po- 
tassium, chloral, Dover's powder, or the succus hyoscyami. 

The membrana tympani should always, if possible, be ex- 
amined when the cause of the disease is not beyond question, 
as there appears to be no doubt that on several occasions 
the symptoms have subsided after incision of the membrana 
tympani, and the evacuation of a small quantity of pus. 

In the more chronic cases, careful feeding is a great 
necessity. There may be some difficulty in swallowing, 
and the bodily conditions are such that any slight broncho- 
pneumonia is too likely to prove fatal. Particular care 
must be enjoined in giving the food to see that no more is 
given than can be readily swallowed, and that the position 
be such that swallowing is made easy. To see a child 
lying flat on its back, and the food tilted in at the angle of 



TUBERCULAR MENINGITIS. 455 

the mouth by gushes, is to foretell a spluttering and insuf- 
ficient meal, and the probable termination of the case is 
broncho-pneumonia. 

Given a case of recovery from the immediate disease, the 
resulting muscular rigidity must be treated by gymnastics, 
faradization, massage, etc. 

3. Tubercular Meningitis. — This disease is sometimes 
called basilar meningitis, because it so frequently and 
chiefly occurs at the base ; acute Jiydroccphalns, for far less 
definite and explicable reasons — at any rate, effusion of 
fluid is no prominent feature in the result. 

Tubercle attacks the brain in two ways — as a diffused and 
more or less acute granular inflammation of the membranes, 
and as a local disease in the form of a yellow mass or tumor. 
For some reason, not easy to give, the tubercular tumors 
are more often situated in the cerebellum or pons. These 
two forms may be found separate or associated, and every 
now and again intermediate conditions are met with which 
make it impossible to separate the two. 

For instance, in the Sylvian fissure, perhaps, the gray 
tubercle may be unusually abundant, and the individual 
granulations large. Some of them may be distinctly yellow. 
Sometimes the granules reach the convexity, and, massing 
themselves into a yellowish layer, spread over the surface of 
some of the convolutions ; sometimes small, yellow nodules 
are scattered over the brain in the depths of the sulci, and 
are found on making vertical slices of the cortical structure. 
The appearance of the tubercular nodule is worth noting ; it 
is invariably surrounded by a gray, gelatinous zone of soft 
vascular material, very similar to the gray, gelatinous mate- 
rial sometimes seen in cases of pulmonary tuberculosis. This 
is the growing tubercle. There is, therefore, in the brain an 
exact counterpart of pulmonary tuberculosis in all its stages, 
even to that of the chronic disease being a frequent cause 



456 DISEASES OF CHILDREN. 

of acute miliary tuberculosis of the part, or of tubercular 
meningitis. 

The brain is usually soft, the central parts may be almost 
diffluent, in tubercular meningitis, and there usually is a 
slight excess of cerebro-spinal fluid at the base and in the 
ventricles ; but this excess is no striking feature, and hardly 
warrants such a confusing term as acute hydrocephalus. 
Occasional conditions — such as patches of red softening or 
acute encephalitis, punctiform hemorrhages, or even, though 
very rarely, a large extravasation of blood — may be met 
with, either in relation to a growing tubercle or to some 
secondary thrombosis of one of the vessels. 

As regards the spinal cord, it is no uncommon thing to 
find it affected in the same way as the base of the brain. It 
follows the rule already laid down, that there is no distinc- 
tion between the two parts. The affection is not always 
present ; occasionally it may be spinal and not cerebral, but 
it is very commonly both. It is very important to remem- 
ber this in a disease of so insidious an onset as tubercu- 
losis ; there are cases in which the symptoms are chiefly 
spinal, such as general 'hyperesthesia, muscular and other 
pain simulating joint disease, or the pain in the neck and 
retraction of the neck already alluded to in simple menin- 
gitis. These features are explained by the spinal affection 
— or may lack any other explanation — in the absence, and 
frequent absence, of cerebral symptoms. 

One other point, which has of late been made much of, is 
the frequency of the existence of tubercle of the choroid. 
Dr. Angel Money found that in forty-two cases of tubercular 
meningitis choroidal tubercle was present in fourteen ; in 
two others it was present, once with a tubercular mass in the 
cerebellum, once without any cerebral tubercle of any kind. 

Histology. — This requires little mention, it is almost beside 
the purpose of this book ; but the details of tubercle may be 



TUBERCULAR MENINGITIS. 457 

well worked out in the pia mater, and perhaps better than 
in other places, in some respects, for here of all parts it has 
such a plain association with the perivascular sheaths. The 
giant cells and reticulum are generally well seen. As re- 
gards the presence of the bacillus tuberculosis in these cases, 
further investigations are wanting. Dr. Goodhart has 
several times failed to find it in cases of pure miliary 
tubercle of the pia mater — that is, in cases in which no 
softening or degenerative changes had occurred. Indeed, 
this seems to be a difficulty in the identification of the 
bacillus as the cause of tubercle, that in just those cases in 
which a specific virus should be most abundant, it is, if the 
bacillus be that virus, least so. 

As regards its association with disease elsewhere, it 
seems that cheesy bronchial glands and a subsequent dis- 
semination of miliary tubercle in the lungs, viscera, and pia 
mater is by far the most frequent occurrence. But it is 
found with other conditions also, such as disease of the 
spine or chronic disease of the bones and joints. It may, of 
course, be the sequel of a chronic phthisis, or with mesenteric 
disease, although these and other conditions appear to be 
far less frequent. If the cases of tubercular meningitis 
spreading from yellow masses in the brain itself, together 
with those in which it is secondary to caseous disease 
of the mediastinal glands, and those in which it is due to 
chronic bone disease, be subtracted, it is probable that the 
remainder, whether from scrofulous kidney, chronic phthisis, 
tabes, etc., would form a very small proportion of the total. 
The amount of disease in the glands is, of course, variable. 
It may be confined to the mediastinal glands, or it may infect 
those above and below the thorax, and even those in other 
parts ; and, in the same way, the accompanying disease in 
the viscera is very variable — the liver, spleen, and kidney 
may look quite natural, except a scattered distribution of 



458 DISEASES OF CHILDREN. 

small gray grains with ill-defined margins visible beneath 
the capsules ; or there may be larger nodules, either in 
spleen or liver, becoming cheesy. In the kidney the nod- 
ules increase, not so much by a circumferential addition as 
by running downward in a streaky way toward the pyra- 
mids. All three of the solid viscera are in some cases 
affected by an infiltration rather than a nodular growth ; 
they then increase much in size and put on a peculiar 
mottled appearance, which is strikingly abnormal. The 
liver is not infrequently studded with nodules of some size, 
which on section show a dilated bile duct, containing often 
retained and perhaps inspissated bile. Tubercle in the liver 
runs along the portal canals, and thus comes to surround 
the biliary canals, and there is this practical import attach- 
ing to it, that tuberculosis in a child is sometimes attended 
with moderate jaundice. Softening of the stomach has 
been described as a frequent lesion in tubercular meningitis. 
The author has never observed any such change himself, or 
one that could not be ascribed to simple post-mortem solution. 

The disease may occur at any age. Of thirty-three 
deaths, one occurred at three months, three at six months, 
one at nine months, three at twelve months, four under two, 
three under three, six under four, four under five, one under 
six, four under seven, and three at eight, ten and twelve 
respectively. 

The course of the disease averages three weeks, but it 
may be rather more prolonged and is occasionally much 
shorter. The duration is, however,- difficult to fix; for, as 
with the earlier days of typhoid fever, the onset often passes 
without recognition. 

Symptoms. — Malaise ; wasting ; bad appetite ; restless 
nights, disturbed by startings and a harsh, painful, short 
cry ; bad dreams ; pain in the head ; confined bowels, and 
some irregularity of pulse. The child is usually paler than 



TUBERCULAR MENINGITIS. 459 

natural, but apt to flush suddenly. These are the symptoms 
of the onset, and, as needs no saying, they are so indefinite 
as to give very little help. With such symptoms as these 
only, one is in danger of being either too foreboding, and 
of condemning many to tubercular meningitis when there 
is some fleeting gastric disturbance, or else of treating as 
trifling what will end in speedy death. Nevertheless, the 
matter can hardly be stated more definitely. As the dis- 
ease matures the cerebral excitement becomes more intense, 
and the special senses suffer exalted sensibility. Thus it is 
that the child avoids the light, starts at sounds, and cries if 
disturbed by movement. The symptoms now are vomit- 
ing ; retraction of the abdomen; intolerance of light ; fever ; 
general hyperesthesia ; stiffness of the neck or other mus- 
cles ; irregular, and sometimes well-marked Cheyne-Stokes', 
respiration ; strabismus ; convulsions ; coma, and a pulse 
which becomes very rapid. 

It is usual to describe tubercular meningitis as a disease 
of stages. The first, of brain irritation, in which headache, 
vomiting, constipation, retracted abdomen, quick irregular 
pulse, excitement, delirium, and convulsions are the chief 
symptoms ; the second, of brain pressure, with pupil symp- 
toms, coma, facial or other local paralysis, hemiplegia, and 
slow pulse, in addition ; and in the third, the paralysis in- 
creased and more general, the pulse again quickening, and 
becoming running, the temperature perhaps falling, but the 
coma continuing. The difficulties of the student, however, 
lie in the stages being confused ; in many of the symptoms 
being absent. Nor is the teacher much better off; for added 
experience only makes it increasingly clear to him how 
treacherous is this disease, and how impossible in some 
cases it is to avoid mistakes. Nevertheless, a careful watch 
of a suspected child will do much toward replacing doubt 
by certainty. 



460 DISEASES OF CHILDREN. 

The child that is hatching tubercular meningitis not only 
wastes and loses appetite, and becomes pale, but he often 
changes in disposition, and becomes cross or fretful, with 
frequent complaint of his head or of being tired. He will 
show a dislike to all noise ; perhaps he will walk with care, 
as if his neck were stiff, or totteringly. There may be some 
slight tremulousness of his arms, an irregular twitching, 
such as one sees from other causes, as from uraemia. As 
the disease progresses, there is a causeless vomiting, uncon- 
nected with feeding, and irregular in its onset. The later 
symptoms are more headache, perhaps drowsiness or stupor, 
a high temperature, though usually an oscillating one, and, 
in the paralytic stage, there may be either general convul- 
sions, tonic spasm of one arm or the other — or of both legs, 
or the whole of one side — or clonic convulsion. The pulse 
may be slow after the first onset, but usually rises again as 
death approaches. 

When convulsions come on, the fatal termination is not 
usually long delayed. The case may drag along for three 
weeks or so in an indefinite way, and the marked cerebral 
symptoms, either convulsions or coma, be not more than 
two or three days in duration ; and there are cases in hospital 
practice where the prodromal stage has been altogether over- 
looked. The child is perhaps brought for convulsions, which 
have ushered in the final stage, and death occurs within a 
short time of admission. Local paralyses are not uncommon, 
particularly of the sixth and seventh nerves. Paresis of arm 
or leg, or of both, is common, but complete paralysis is rare. 

In young children, before the fontanelle has closed, there 
may be bulging, the surface veins may be distended, and 
there may be evident head pain denoted by the' restless 
knocking of the head with the hands, or, when asleep or in 
its cot, by the frequent harsh encephalic shriek which is so 
painful to the hearer. 



TUBERCULAR MENINGITIS. 46 1 

The optic discs should in all cases be carefully examined 
for changes at the fundus. But in the majority of cases 
these are not marked, and would pass unrecognized by any 
but the most skilled observers. There is even a difference 
of opinion among those most competent to form an opinion 
— some averring that changes may be seen in many cases, 
others that they are exceptional. The morbid changes are 
of two kinds : I. Evidences of swelling and inflammation ; 
2. The presence of choroidal tubercle. The latter is unques- 
tionably rare. As already said, there is every probability of 
tubercle existing in the choroid, either as minute grains, to 
which Barlow has applied the term " tubercular dust," after 
Rilliet and Barthez, or in larger tubercles, but which pass 
unrecognized during life. Dr. Goodhart had a case in the 
Evelina Hospital where there were many in each eye; one, 
in the neighborhood of the yellow spot in the left eye, had 
a central glimmering whiteness, surrounded by a dark, 
blurred halo, which might well have passed for a patch of 
choroiditis of some date. All the others were far less pro- 
nounced departures from the normal tint of choroid. They 
seemed as a pearly or gray pallor of it, hardly to be called 
swollen, yet to careful sight the vessels were blurred, nar- 
row and distorted, while one or two of the spots were 
noticeably perfectly circular. But to be able to be sure of 
the presence of tubercle in the choroid by an ophthalmo- 
scopic examination is certainly the rare exception. It is 
more common by far to be able to detect some increase in 
size or tortuosity of the veins, some alteration of the vessels 
from day to day, some swelling of the disc, some slight 
cloudiness of the edge, or lymph-like grains about its edge, 
which tend to obscure the vessels. Of the frequency of 
these appearances there must of necessity be different 
opinions; of their value if present, some latitude must also 
39 



462 



DISEASES OF CHILDREN. 



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TUBERCULAR MENINGITIS. 463 

be allowed to individual observers. The conclusion will 
necessarily depend upon how much range is allowed for 
the variations in the appearances of the normal disc. In 
Dr. Goodhart's cases pronounced changes of any kind have 
been quite exceptional. For a statement on the other side, 
it may be said that Dr. Garlick, in some observations made 
in the Ormond Street Hospital, found them in 80 per cent, 
of the cases.* 

Temperature. — The chart of tubercular meningitis is likely 
to show considerable excursions. Of twelve cases, it was 
over 105 ° in three, and in a fourth ran up to that height at 
death. In two others it went to 104 . In three it was not 
over 100.5 . The oscillations are often considerable; even 
as much as three or four degrees. The highest point 
reached daily is irregular ; sometimes it is in the morning, 
sometimes it is high both night and morning, sometimes 
one day at night and another in the morning. 

The accompanying temperature chart (Fig. 8) was taken 
from a case at the Children's Hospital, Philadelphia, Jennie 
G., aet. six years. Attention is called to the oscillation of 
temperature on the sixteenth day. 

Of the many symptoms, some are more reliable than 
others. Of these are, irregularity of pulse and respiration, 
vomiting, for which no cause can be assigned, intolerance of 
light, headache if accompanied by retracted abdomen, stiff- 
ness of the neck, and hyperaesthesia of the surface. Strabis- 
mus and convulsions are, of course, equally reliable in their 
place ; but they usually come at a time when doubt has 
given place to certainty. 

Diagnosis. — Typhoid fever is the great difficulty ; in it 
even strabismus has been known to occur, as if to make the 
symptoms of the two diseases exactly similar. If, after pay- 

* " Med.-Chir. Trans.," vol. LXii,*p. 441. 



464 DISEASES OF CHILDREN. 

ing all attention to the previous history and surroundings 
of the patient, there is still doubt, one must withhold one's 
judgment. Retraction of the abdomen, hyperesthesia, and 
irregularity of pulse, are here especially valuable indica- 
tions. Vomiting fails, as it may be present and severe in 
early typhoid ; still, in meningitis, it is usually erratic, 
rather than of the urgency of a typhoid condition. Con- 
stipation is of little value, it is so often present in typhoid 
fever ; but it and retraction of the abdomen are not com- 
monly associated in the latter. The splenic enlargement 
sometimes gives a hint. The tache cerebrale is found under 
such a variety of conditions as to be of little use. 

From simple meningitis, in the absence of any local source 
for that affection, it cannot be distinguished with any cer- 
tainty. Dr. Goodhart suggests that the temperature runs 
higher in simple than in tubercular meningitis ; but it does 
not appear that this is so on an appeal to facts. Simple 
meningitis is, however, likely to be more sudden in its on- 
set, acute in its symptoms, and rapid in its course. Steiner 
notes that it may sometimes require the greatest skill to 
distinguish between meningitis and chronic hydrocephalus. 
The author has seen a case of hydrocephalus terminated in 
meningitis of a few days' duration ; but although the cere- 
bral symptoms were not unlike those of meningitis, yet the 
temperature was persistently low throughout the illness and 
until just before death. 

It may sometimes prove difficult to decide at the moment 
between tubercular meningitis and acute gastric disturb- 
ance. Attention must be given to the previous state of 
health — tubercular troubles maturing slowly, gastritis sud- 
denly. Moreover, the latter is wont to occur at the time of 
dentition, and to be associated with a foul tongue, whereas 
in tubercular meningitis the tongue is frequently clean at 
the onset. 



TUBERCULAR MENINGITIS. 465 

Prognosis. — This is as grave as it can be ; but instances of 
recovery are recorded, and, in this regard, we have fre- 
quent opportunities of noting an important piece of evidence, 
for it often happens that yellow tubercle in the brain has 
obviously been where it is found a long time, and yet has 
caused no symptoms. We have evidence, then, that masses 
of tubercle, which have been slowly growing, may give rise 
to no symptoms ; and that simple meningitis has repeatedly 
recovered. There seems, therefore, no reason why tuber- 
cular meningitis should not occasionally recover, and there 
is much evidence that it actually does so. Rilliet and 
Barthez, Meigs and Pepper, and Clifford Allbutt, all concur 
in the occasional occurrence of such cases. The author 
believes that he has seen a case of the kind. We can 
hardly reach much more than the belief, because recovery 
precludes the verification, and there must always remain 
behind a doubt whether the case might not have been one 
of simple meningitis. But we may at any rate say that the 
facts are sufficient to justify us in affirming that the case is 
not absolutely hopeless. 

Treatment. — Iodide of potassium should always be given, 
in the hope that, under its use, the symptoms may possibly 
ameliorate. The liquor hydrarg. perchlor.* may also be 
given, in twenty- or thirty-drop doses, or more. It may 
act as a promoter of absorption of inflammatory products, 
and it is not a form of mercury which has any harmful 
action upon children. Here, also, the author has of late 
been trying iodoform internally, in quarter- or half-grain 
doses, in very young children, and increasing it cautiously, 
if necessary, to one grain or even more. As already said, 
it requires watching, as it occasionally makes them sick. 



* Liq. Hydrarg. Perchlor., Br. P., contains ten grains each of perchloride of 
mercury and chloride of ammonium to a pint of distilled water. 



466 DISEASES OF CHILDREN. 

Cases of phthisis have done well upon it, but any marked 
effect upon tubercular meningitis has not been noted. 

The child should be kept in bed, and perfectly free from 
excitement of any kind. An ice-cap should be kept to the 
head ; the bowels acted upon once a day ; and any headache 
or sleeplessness mitigated by bromide of potassium, chloral, 
or opium. The diet should be highly nourishing and easily 
digested, in the shape of eggs, milk, jellies, custard, etc. 

Children with hereditary tendency to phthisis, or those 
who look tuberculous, should be carefully watched and 
guarded. In infants a tuberculous mother should not 
nurse her child, but let it be fed artificially or by a wet- 
nurse. It must be kept warm, live as much as possible in 
a dry air, upon a porous soil, and the development of its 
brain must be delayed as much as possible by keeping it 
away from books. 

4. Hydrocephalus. — The term chronic hydrocephalus 
may be dismissed, because it is misleading. Hydroce- 
phalus has often been a bugbear with students, because of 
the difficulties which have been made to exist by a descrip- 
tion of three so-called varieties — acute, chronic, and false 
hydrocephalus. Acute hydrocephalus has been accepted 
as synonymous with tubercular meningitis, but in the pre- 
ceding chapter it has been pointed out that the effusion is 
usually of subsidiary importance, it is so small in quantity. 
The diagnosis is not made by the evidence of excess of the 
cerebro-spinal fluid, but by the evidence of inflammation of 
the membranes of the brain. Cerebro-spinal fluid is often 
in excess, but the excess is mostly a moderate one, and 
there are many reasons for questioning the influence of the 
fluid in the production of a fatal result. But both in this 
and in simple meningitis, particularly when of a more 
chronic form and associated with the formation of a large 
quantity of sero-purulent fluid, the ventricles may become 



HYDROCEPHALUS. 467 

somewhat rapidly dilated, and be so found at the post- 
mortem ; and, probably, the younger the child the more 
likelihood will there be of this. 

False hydrocephalus is a perfectly distinct affair, and 
need no more be introduced into the subject, than when 
discussing coma or collapse it is necessary to call one form 
true uraemic coma, for example, and all others false uraemic 
coma. It may be met with in any of the wasting diseases 
of childhood, but is most common during the later stages of 
inflammatory diarrhoea. It is a result of exhaustion. 

The symptoms are drowsiness, half-closed eyelids, slug- 
gish and unequal pupils, pinched features, livid complexion, 
sunken fontanelle, subnormal temperature, rapid intermit- 
tent pulse, and irregular sighing respiration. The drowsi- 
ness gradually deepens into coma, and slight convulsions 
may precede death. 

False hydrocephalus may depend upon the slow circula- 
tion of impoverished blood through the brain, upon the 
formation of thrombi in the cerebral sinuses, and, according 
to Parot, on uraemic poisoning, the symptoms being often — 
in cases of diarrhoea, for example — associated with marked 
diminution in the secretion of urine. 

The main treatment is the use of stimulants, both inter- 
nally and externally. 

Hydrocephalus is a disease which occurs under limited 
and definite conditions, and it is a disease which has fairly 
definite symptoms. As with all other diseases, these are 
sometimes less distinct than at others, and the diagnosis 
may be mistaken or doubtful ; but difficulties in diagnosis 
are not peculiar to it, it shares them with every other disease 
that can be mentioned. By hydrocephalus we understand 
an equable enlargement of the cavity of the skull by fluid 
within the cerebral ventricles, and by which it tends to 
become more globular. The globular shape is somewhat 



468 DISEASES OF CHILDREN. 

interfered with by reason of the union with the facial bones 
in front, but, wherever it is possible, bulging takes place — 
at the fontanelle, which becomes much increased in size, at 
all the sutures, and at the roof of each orbit. Thus the 
breadth of skull increases from side to side, the frontal 
bones become protruded forward and expanded, the eyeballs 
are prominent and their axes divergent. Within the cra- 
nium the brain is converted into a cyst, the larger in pro- 
portion to the dilatation of the ventricles by the accumu- 
lated fluid. The cortex cerebri lies everywhere in contact 
with its case. A distinction is made between external and 
internal hydrocephalus — in the one case the fluid being out- 
side the brain, between the skull and it, and in the other 
inside. The external form will be considered presently, 
but now it will be sufficient to say that internal hydro- 
cephalus is the common form, and whether the external 
should receive the name of hydrocephalus at all is doubt- 
ful. Hydrocephalus, then, is usually a cystic expansion of 
the brain by fluid within the ventricles, so that, if we were 
about to remove the fluid by tapping, it would be necessary 
to pass through the skull or its membranous equivalent, 
the dura arachnoid, the pia arachnoid, and the gray and 
white matter of the cerebral cortex, to get at the fluid. 

The bones of the skull in such a case are usually thin, 
sometimes so thin that there may be craniotabes. The fon- 
tanelles and sutures are perhaps widely gaping or filled up 
more or less by the formation of Wormian bones. 

Morbid Anatomy. — The brain is more or less expanded 
into a loculated cyst by the dilatation of all the ventricles 
and the iter. In extreme cases the cortical layer becomes 
so thin that it is impossible to remove the brain without 
laceration. If this can be done, and the brain taken out with 
a sufficiency of fluid in the ventricles, the appearances at the 
base may be somewhat peculiar from the dilatation of the 



HYDROCEPHALUS. 469 

third ventricle and the infundibulum. A thin-walled trans- 
parent cyst is seen, upon which the optic nerves, corpora 
albicantia, etc., are perched. Sometimes the optic nerves are 
cedematous. The lining membrane of the ventricles may, 
perhaps, be a little thickened and tough — it sometimes has 
the appearance of being dusted with sand, but its appear- 
ance is otherwise normal. These conditions are important, 
because they serve to explain one or two clinical facts. In 
the first place, the extreme swelling of the parts about the 
optic tract and the chiasma may serve to show why there 
should be, as there sometimes is, white atrophy of the optic 
discs and blindness. The dilated condition of the fourth 
ventricle may explain how such cases die suddenly. The 
fourth ventricle is sometimes so much dilated that all the 
parts become stretched over it, and the circulation through 
the medulla and pons must almost necessarily be disar- 
ranged, and the nutrition of those parts be feeble. 

The morbid changes which lead to hydrocephalus are not 
many, and their action is easily intelligible. The following 
is, perhaps, their common order of occurrence : (i.) Tumor 
about the cerebellum, pons or tentorium. (2.) Chronic 
inflammation about the medulla and cerebellum, leading 
to adhesion about the margins of the foramen magnum. 
(3.) Congenital malformation. 

These, no doubt, act in one of two ways. They may press 
upon the veins of Galen and the straight sinus, or they may 
close the communication between the interior of the ven- 
tricles and the rest of the sub-arachnoid space. It might 
be thought that the pressure upon the veins, and the obsta- 
cle thus produced to the return of blood from the choroid 
plexuses, would be a sufficient and readier explanation of 
all cases ; but it seems clear, from the occasional occurrence 
of congenital malformation, or the post-congenital adhesion 
and blocking of the aqueduct of Sylvius, that the mere 
40 



47° DISEASES OF CHILDREN. 

closure of the ventricles is sufficient for the production of 
the affection. 

Of chronic inflammation about the cerebellum and bulb 
it may further be said that it not improbably originates in 
a variety of causes : there is the basal meningitis of infants, 
described by Dr. Gee and Dr. Barlow, of which some are 
certainly syphilitic ; there are the insidious forms of menin- 
gitis which keep company with bad hygiene and the exan- 
themata ; there is the group dependent upon otitis of the 
middle ear ; and, lastly, the author would, least of all, ex- 
clude injuries to the head, for although, in the popular 
estimation, infants are providentially provided with bones 
that seem little liable to break, it cannot be said that 
they possess brains which are equally callous to bruising. 
Other causes are mentioned, such as inflammation of the 
lining membrane of the ventricles, and true dropsy of the 
ventricles. Of the first it may be said that it is very rare, 
except under circumstances such as given in a case of sim- 
ple meningitis (p. 449). Meigs and Pepper think otherwise 
and state that in many cases the lining membrane of the 
ventricles is granular and much thickened. They also 
state, in correspondence with this, that the fluid drawn off 
in these cases is frequently like the effusion in pleurisy or 
pericarditis ; but here, again, except in one acute case, the 
author has seen nothing in the ventricles in these cases but 
natural-looking cerebro-spinal fluid, even when there has 
been distinct evidence of bygone inflammations, shown by 
adhesions about the base of the brain. Hillier states that 
dropsy may occur from obstructed veins either from simple 
or pyaemic thrombosis. This would be a form of disease 
of similar origin to that of other cases — viz., obstructed 
venous circulation ; therefore whether there is such a thing 
as spontaneous dropsy of the ventricles, apart from such a 
cause, must still be a matter of conjecture. Rickets is said 



HYDROCEPHALUS. 47 1 

by many to be a cause of this disease, but the evidence in 
proof of this derived from actual demonstration in the post- 
mortem room is very scanty. This discrepancy is, how- 
ever, readily explained and is not uninstructive. This 
description is drawn from extreme cases, such as no one 
would hesitate about — children with very large heads, and 
in whom the enlargement has existed for a long time. But 
if we are less exclusive in the ascription of hydrocephalus, 
then, no doubt, there are many cases, mostly in children of 
a younger age (under a year), in which the head enlarges, 
the veins become turgid, there are symptoms more or less 
of meningitis, and the ventricles contain a considerable 
excess of albuminous fluid, which is turbid, or flaky or 
even purulent — cases which, because they are more acute 
in their onset, less lengthy in their duration, and some of 
them more amenable to treatment, Dr. Goodhart would 
remit to the domain of meningitis, and possibly sometimes 
even to that of congestion only. The subject is one of 
difficulty, because it is possible that the inflammatory con- 
dition of the ependyma, etc., might fall short of an intensity 
which kills, and gradually subside into the chronic state 
which has been described as the typical disease. It is not 
proved that this is so, and, except for possibly rare occa- 
sions, the author believes that the two classes of cases are 
distinct. 

It must not be omitted that most writers hold a different 
opinion, and Dr. Dickinson proposes a classification which 
has much to be said in its favor. He divides the subject 
into two : (i) cases due to pressure of fluid within the cra- 
nium ; (2) cases dependent upon diminished resistance of 
the walls without. In the first group come such as depend 
upon pressure on the intra-cranial sinuses and plexuses and 
inflammation of the lining membrane. The second group 
is practically confined to rachitic softness of the skull, 



472 DISEASES OF CHILDREN. 

which, in failing to give adequate support to the brain, 
favors the effusion of an excess of cerebro-spinal fluid. 

Of twenty cases, seventeen were in boys, three only girls. 
Their ages : two of three months, two of six months, eight 
between six and twelve months, three at eighteen months, 
one two years, three four years, and one five years old. 

Symptoms. — It is difficult to say much about the early 
onset of the symptoms. In some the enlargement dates 
from intra-uterine life. In one or two the complaint has 
come on suddenly after convulsions, or some acute illness ; 
but fifteen out of the above twenty cases had a history of a 
gradual enlargement since the child was two or three months 
old. As to definite symptoms there were generally none. 
Wasting was noticed in four ; two had head pains — one so 
severely that the skull was tapped to relieve the pain, and 
with some success ; two had crowing respiration, a symp- 
tom noticed by West ; one, giddiness. The increase in 
size is very slow, and often oscillating. In eleven cases 
measurements were taken from time to time. One had 
increased ^ inch in three and a half months ; another, I 
inch in two months; another, beginning at ijyi inches, 
had gained y^ of an inch in a month, lost y 2 of an inch in 
three months, and then increased to 18^3 inches in three 
and a half months ; another remained stationary. There 
had been no fever in these cases. 

As the disease progresses, and the intra-cranial pressure 
begins to tell, the child wastes ; sometimes it has convul- 
sions ; ultimately it becomes blind, has nystagmus, and so 
dies gradually exhausted. Once or twice there has been 
some rigidity of the limbs; once retraction of the head. 
An examination of the eye in the later stages may show a 
swollen or inflamed disc, or a white and atrophied one. 
The latter has been more common in my experience. The 
cerebral symptoms vary much. The cases Dr. Goodhart 



HYDROCEPHALUS. 473 

has seen seemed to him to present an average intelligence ; 
sometimes an old-fashioned pseudo-precocity, such as 
Jenner pictures in rickets, unless the enlargement be ex- 
treme. In the latter case there has usually been blindness, 
intelligence has failed more or less completely, and the child 
lies in bed taking notice of nothing. It feeds and sleeps ; 
perhaps leads a painless existence ; perhaps exhibiting 
some signs of pain on movement. It is not often that one 
has the opportunity of tracing cases on from the early stage 
of the disease to its completion. They are met with either 
early or late ; if the former, then the symptoms are of 
equivocal meaning ; in the late stage, the wasting, the 
pain, the blindness, and the enormous head cannot be mis- 
taken. 

Diagnosis. — The term " water on the brain," both to doctor 
and the public, occupies a very similar position in cerebral 
nosology to consumption of the bowels for abdominal dis- 
eases. It is the refuge of the destitute, and has often been 
made to apply, not only to acute and chronic brain disease, 
but also to the convulsions of rickets or teething, the onset 
of an exanthem, or one of the many gastro-intestinal de- 
rangements which maybe met with in profusion. The first 
point in the diagnosis is to eradicate from the mind the 
notion that a bulging fontanelle of necessity indicates excess 
of fluid in the ventricles. It much more often means merely 
a congested brain. Not long ago the author saw a child 
with Mr. Irwin Palmer, which had had constant convulsions 
for four days, an unusually bulging anterior fontanelle, a 
widely open posterior fontanelle, a retracted head, and a 
wearing cry. There were many points in favor of some 
acute meningitis with effusion. But another view seemed 
quite possible ; dentition was proceeding ; and the parents 
asserted that food brought on a fit ; the diet was accord- 
ingly reduced, chloral and bromide of potassium given to 



474 DISEASES OF CHILDREN. 

quiet and thus lessen the loaded cerebral circulation, and the 
treatment was quite successful. There can be no doubt that 
in this case there was no meningitis and no effusion. We 
must look suspiciously upon all cases of supposed sudden 
effusion, and first determine whether there be not some 
temporary cause in the form of preceding or threatening 
convulsions for the swelling of the fontanelle. If the bulg- 
ing be persistent, and the head slowly enlarges, if there be 
head pains certainly not of rachitic origin, then we may begin 
to think of hydrocephalus. In making a diagnosis the 
characteristic features of hydrocephalus are a very gradual 
increase in the size of the head, without any pyrexia, and 
often without any evidences of ill-health. There may be a 
history of bygone meningitis, or something which denotes 
the present existence of some cerebral tumor. It is liable 
to be mistaken for rachitic enlargement of the skull, but 
this cannot be often. The rachitic skull is quite different. 
It wants the enlargement in all directions which is seen in 
the hydrocephalic skull, and thus the width and overhang- 
ing of the forehead, and the prominent and divergent eye- 
balls. The rachitic skull is long and laterally compressed, the 
forehead is high and square, and the bones may become 
thickened, soft, and tender. Moreover, there is the evidence 
of rickets elsewhere, and the evidence of tender bones in all 
parts. The two diseases, however, may be associated. 

The disease may perhaps be confounded with hypertrophy 
of the brain, which will be described later ; but this condi- 
tion is so rare and obscure, both in its symptoms and in the 
morbid changes which produce it, that no definite means of 
distinguishing it can be given. 

Prognosis. — A case of advanced hydrocephalus lives, at 
best, a precarious life ; but it is certainly instructive to 
notice how long the less serious cases live. Children thus 
affected attend at hospitals for a year or two — at any rate, 



HYDROCEPHALUS. 475 

for several months — and then disappear from view ; and it is 
probable that many of the moderate cases hold their own, 
and, so to speak, get well. The pathology of hydrocephalus 
is a subject of great interest. Space has, unfortunately, pro- 
hibited entering upon it; but putting aside such cases as 
are due to incurable conditions, such as pressure upon the 
veins by cerebral tumors, there is no reason why, if hydro- 
cephalus be due to the shutting off of the ventricles from 
the general sub-arachnoid space, the ventricular cavities 
should not strike a balance in many cases, as is often seen 
in hydrocele, for instance, and the equilibrium of secretion 
be restored. Whether this be so or not we cannot tell, but 
this much is certain, that hydrocephalic heads in consider- 
able number are seen in the out-patient room at children's 
hospitals. The general health of these children, as a rule, is 
not bad ; the evidences of cerebral trouble are few or none ; 
the enlargement of thehead is very slow, and often stationary ; 
the majority are ultimately lost sight of, and only the few 
extreme cases are known to die. Even these linger for a 
long time, perhaps fairly intelligent, most probably dull ; 
but in the end intelligence fails, sight fails, and the child 
lives a vegetative existence. Death comes sometimes by 
convulsions ; sometimes suddenly ; sometimes by pro- 
gressive emaciation, deepening stupor, failure of the respira- 
tory centres, the accumulation of mucus in the bronchial 
tubes and asphyxia; or else, by failure of deglutition, food 
enters the air-passages, and latent broncho-pneumonia 
develops. Of such of the less severe cases as are associated 
with rickets Dr. Dickinson speaks almost favorably. " In 
those more numerous cases of chronic .hydrocephalus," he 
writes, " in which the enlargement has not been heralded by 
convulsive vomiting, or any other sign of cerebral disturb- 
ance, in which we may infer that the fault is in the cranium 



4?6 DISEASES OF CHILDREN. 

rather than in the brain, we can generally relieve and some- 
times cure." 

Treatment. — Unfortunately, one is not often in a position 
to be able to come to any conclusion as to what is the cause 
of the disease. All that is possible, in many cases, is to 
hope for the best, that there may have been some bygone 
local inflammation, the effects of which being tided over, 
the equilibrium of secretion may be restored. 

In all cases, therefore, it seems to be advisable to apply 
systematic support to the exterior of the skull as long as 
possible, and — in the hope, again, that something capable 
of absorption may be present — from time to time some 
mercurial ointment or oleate of mercury (five per cent, sol.) 
may be applied, or some iodide of potassium ointment 
rubbed in. This treatment has been recommended by Golis, 
Trousseau, West, and others ; and, although it will often 
fail, it sometimes seems to do good. It must be carried out 
with care. A child's skin is a very delicate texture, and 
the strapping requires to be frequently changed and the 
surface rested, otherwise ugly sores may be made which 
hinder the treatment very seriously. It is better, therefore, 
to strap for three or four days, and then rest a day or two, 
during which time the surface must be regularly and care- 
fully cleansed and bathed now and again with some spirit 
lotion. Obviously, to carry out the intent of the treatment, 
the head should be strapped continuously for as long as 
possible, and the intervals for rest be as short as is compat- 
ible with the preservation of the skin. Internally, iodide of 
iron may be given, or cod-liver oil. Careful attention to 
feeding must be given if the child be wasting. 

As regards tapping, it is not often successful, but there 
does not appear to be much risk attaching to it. Therefore, 
in advanced cases, if the skull is not too consolidated to 



EXTERNAL HYDROCEPHALUS. 477 

allow of it, and the child be wasting and in any pain, it ap- 
pears to be worth the trial. The parents must be prepared 
for the possibility of convulsions after and a possibly fatal 
result, and for no very visible success in the way of relief. 

A fine trocar and canula are used and passed into the 
lateral ventricle in the coronal suture at the outer angle of 
the anterior fontanelle, or at a distance sufficient to well 
clear the longitudinal sinus. The amount to be drawn off 
is usually limited by the amount that flows readily, and 
which is often not much. The bones must be carefully 
supported during the flow of fluid ; and, as soon as the 
tension inside the skull is insufficient to expel the fluid, 
the canula should be withdrawn and the head carefully 
strapped. In one case, the fluid withdrawn allowed the 
bones at the sagittal sutures to overlap each other, and the 
head assumed a most peculiar appearance from the lateral 
compression that followed. Pressure was kept up by strap- 
ping, and the fluid never reaccumulated. The child was 
alive and in good health eighteen months afterward. In a 
second case, in a younger child with more acute symptoms, 
tapping was resorted to for the relief of the tension and the 
pain, only two ounces of fluid would flow but the pain was 
certainly relieved. The child died a fortnight later, but 
death had been expected, as there was in all probability 
some meningitis associated with it. In a third case, tap- 
ping was resorted to, but very little fluid would flow, and 
the operation did neither good nor harm. 

Dr. Goodhart has seen three or four more cases treated 
thus in the practice of others, and in none has any harm 
resulted. 

External Hydrocephalus. — This term applies to fluid col- 
lected outside the brain, either in the arachnoid or some 
sac formed either in, or in connection with, one of the mem- 
branes. The origin of this condition is obscure. Most 



47§ DISEASES OF CHILDREN. 

authors speak of it as due to hemorrhage into the arach- 
noid, and subsequent changes in the clot. It and pachy- 
meningitis interna, or blood cysts of the dura arachnoid, 
are not easily to be distinguished, and the latter are now 
generally believed to be of inflammatory origin. It is also 
occasionally associated with atrophy of the brain, the result- 
ing vacuum being filled by cerebro-spinal or serous fluid. 

Symptoms. — This condition can hardly be said to have 
any that are well recognized as belonging to it ; but, being 
a cortical affection, it might be expected to be more associ- 
ated with convulsions and rigidity of the limbs on one side 
or the other. 

Diagnosis. — Such a case will present great difficulties. It 
will depend much upon the irregular shape of the head, 
such as a local bulging in one part or another, or, perhaps, 
a condition of craniotabes. Perhaps it may be well to say 
that local enlargement of the head is a characteristic of 
some tumors, particularly of the posterior segment in cere- 
bellar tumors. 

Treatmeiit. — This form often gives more hope of success- 
ful treatment. Tapping, and even repeated tapping, has 
already cured such cases; and it seems reasonable to hope 
that, with all the modern improvements in surgical pro- 
cedure, tapping or other means for removing the fluid • 
might be carried out with a fair chance of a permanent cure. 

5. Encephalic Tumors. — The brain substance may be 
occupied by tumors of many kinds, but the large proportion 
of those which occur in childhood are of a tubercular nature, 
and are situated for some reason or other in the cerebellum, 
or, at any rate, below the level of the tentorium cerebelli. 
That masses of tubercle should be a frequent cause of dis- 
ease of the brain in childhood is only what might be 
expected, when we remember the remarkably lymphoid 
structure of the perivascular spaces in the brain, and the 



ENCEPHALIC TUMORS. 479 

frequency of tubercular meningitis. It is less easy to say 
why the cerebellum, and perhaps the pons, should be so 
frequently attacked. Several reasons might be suggested, 
but inasmuch as no single one carries any conviction of its 
sufficiency, they need not be stated. The fact remains — 
tubercular tumors are very common in the cerebellum and 
the pons Varolii. The realization of this carries with it an 
aid to the diagnosis of the several varieties of intra-cranial 
tumors. Growths of other kinds are also more commonly 
seated below the tentorium, and they are usually of glio- 
matous or sarcomatous nature. The central ganglia, the 
peduncles, and the cortex are attacked more rarely. 

Symptoms. — It is well known that tumors of the cerebral 
substance, unless they are of large size or attack particular 
strands of nerve substance, give very indefinite signs of 
their existence. Should they be in the motor area of the 
cortex, a monoplegia may result, or a localized weakness or 
convulsion in this or that group of muscles. But, for the 
most part, one has to be content with headache — mostly, it 
may be said, of paroxysmal kind — and vomiting. Tumors in 
the cerebellum or pons give symptoms which very seldom 
allow room for mistake. These are — intense occipital head- 
ache and vomiting, congestion, swelling, and neuritis of the 
optic nerves, followed by white atrophy and blindness, a 
reeling gait, tonic convulsions or rigidity, movements of 
the eyeballs, enlargement of the occipital segment of the 
head, and hydrocephalus, or craniotabes. Some of these 
are symptoms we should naturally expect from a tumor, at 
any rate, of any size, taking up its position in parts closely 
surrounded by such unyielding structures as confine the 
posterior fossa of the skull. We are familiar with the rend- 
ing pain of an abscess pent up in fibrous structures, and it 
is more than likely that a tumor in the region in question 
acts similarly — it deranges the circulation, produces con- 



480 DISEASES OF CHILDREN. 

gestion, tension, and other abnormal relations in parts of 
a sensitive and vital activity, and the resulting distress is- 
the natural outcome. Hydrocephalus is also easily expli- 
cable from the pressure upon the tentorium which must 
ensue, and the consequent liability to closure of the veins 
of the choroidal plexuses, or of the communications between 
the ventricular cavities and the sub-arachnoid space. The 
unsteadiness of gait is also a well-known feature of cere- 
bellar disease ; rigidity, also, and movements of the eye- 
balls. These have all been proved to occur by experiments 
made by Ferrier with the object of determining the func- 
tions of the cerebellum. Some of these symptoms are 
more constant than others, and of particular importance are 
the unsteady movements in walking and evidences of optic 
neuritis or congestion. These are rarely wanting, and 
optic neuritis particularly may be an early symptom. Rigid- 
ity comes next. Perverted movements of the eyeballs are 
less constant; and enlargement of the head is often absent, 
and can hardly be expected where the bones of the head 
are ossified. In this case there may be craniotabes. 

Morbid Anatomy. — Solitary tubercle is the commonest 
form of tumor in the cerebellum, and its most favorite seat 
appears to be the posterior part of one or other lateral lobe ; 
occasionally there is a smaller mass in the opposite lobe. 
But other tumors exist sometimes — gliomatous growths and 
either cystic tumors or simple cysts. The latter, although 
not common, may be kept well in memory. The author 
has seen some five or six cases, and one can never see a 
fatal ending in such as these without regretting that sur- 
gery was not allowed a chance to cure. 

Diag7iosis. — The symptoms of cerebellar tumor admit, as 
stated, of little mistake ; but it must, of course, be under- 
stood that tumors in this part are liable to implicate by 
continuity the neighboring parts, and thus produce other 



ENCEPHALIC TUMORS. 48 I 

symptoms. Tumors in the pons Varolii, or growing from 
the tentorium, might compress or spread to the cerebellum, 
and thus produce the symptoms* of a tumor of the latter. 

A tumor, if located in the pons, may produce nothing but 
general tremor of the acting muscles. More often there is 
some paresis of the extremities on one or both sides ; some- 
times paralysis of the third or sixth nerves, and so on. 
Gliomata in the pons, moreover, have a tendency to enlarge 
the pons uniformly, so that, on section, the disease looks 
more hypertrophic than of foreign material, but when they 
reach the surface, they may become sub-lobulated and 
implicate the trunks of the neighboring nerves. Dr. Good- 
hart has seen three such gliomatous enlargements, of one 
of which a short note follows. A boy of nine years was 
stated to have been quite well one month before his admis- 
sion. He then began to fall about, complained of inability 
to swallow his food, and once or twice almost choked. He 
was admitted with right facial paralysis and paralysis of the 
right side of the tongue, and a staggering gait. His optic 
discs were normal (this seems to be a point in the case 
which might prove of diagnostic importance in similar 
cases). After a short stay in hospital, he gradually lost 
power in his left arm and then in his left leg, and lastly he 
became rigid on both sides. He died in a semi-comatose 
state. At the post-mortem, the entire pons and medulla 
were swollen by a general hypertrophic enlargement, so 
that it was impossible to say, from the naked-eye examina- 
tion, where the disease began or ended. The surface of the 
tumor was very peculiar from the number of small lobules 
over it, and which gave it somewhat the appearance of the 
wattles of a fowl. Dr. Angel Money has described two 
similar cases,* and gives a typical representation of one; Gee 

* " Med.-Chir. Trans.," vol. lxvi. 



482 DISEASES OF CHILDREN. 

and Kidd have each recorded another, and it is probable 
that others have gone unrecorded rather than that they 
are very rare. Gliomata are slowly-growing tumors; they 
infiltrate the part, so that it is impossible to state precisely 
the boundaries of the growth. Between tumors of the pons 
and cerebellar tumors it will sometimes be difficult to decide. 
The existence of muscular feebleness, or general paralysis, 
or local paralysis of the nerves, will be in favor of the affec- 
tion being located in the pons ; and it may probably be said 
that, given a lesion limited to each part, the muscular irreg- 
ularity is more of a general tremor when the lesion is in 
the pons — a more irregular and jerky form of ataxia when 
the cerebellum is affected. Rigidity may, it would seem, 
go with either. The position of tumors elsewhere must, 
of course, be assigned upon similar grounds — viz., by the 
perverted or banished functions of the part in which they 
are situated, over and above the fundamental disturbances 
of headache and vomiting. For instance, if the growth be 
in the cortex, there may be some local paresis of muscular 
movement, some erratic muscular action, either spasm or 
convulsion, some defect of sensation, of moral sense or 
intelligence. 

Prognosis. — This resolves itself into a question of dura- 
tion. If we can, by the general aspect of the case, exclude 
a mass of yellow tubercle, then glioma, being the next most 
probable condition, is liable to go on a long time, but the 
ultimate result is no less sure. Tubercular masses also are 
sometimes of very slow growth, and sometimes become 
quiescent for a time, but ultimately they cause death, either 
as tumors, or by the extension from their margins of a 
tubercular meningitis. 

Treatment. — With perhaps an exception to be mentioned 
directly in the case of simple cysts, the treatment resolves 
itself into the relief of pain and careful nursing. For the 



HYPERTROPHY AND SCLEROSIS OF THE BRAIN. 483 

relief of pain, iodide and bromide of potassium, chloral 
hydrate, or opium must be given ; and in one case, these 
means being insufficient and the pain apparently terrible, 
one may consider himself justified in resorting to trephining. 
Dr. Goodhart resorted to operation in a child of three years, 
with evident indications of a cerebellar tumor. Mr. Jacob- 
son trephined the skull in the left half of the posterior fossa, 
as low down as possible, so as to avoid the lateral sinus; 
and in the bare hope that the tumor might be cystic, a fine 
trocar was passed into the cerebellum, but without any 
result. The trephine wound was made as large as possible, 
with the idea of relieving the tension below the tentorium, 
and for a time the screaming fits were somewhat relieved. 
The part healed very rapidly, and deep down in the neck a 
firm membranous covering closed in the aperture, but the 
relief gained was not for long. The case ultimately proved 
to be tubercular. Nevertheless, this treatment seems to be 
worthy of consideration, not only for the relief of pain, but 
in other cases for another reason — viz., the tendency that 
exists in the cerebellum for the formation of simple cysts. 
There is no means of arriving at a diagnosis without the 
trephine, and it seems to be quite worth the while, in a 
disease which is hopeless without it, to give the patient just 
the faint chance an operation offers of coming upon a cyst 
and evacuating its contents. Modern antiseptic surgery has 
taken away much of the danger that attached in former 
times to trephining, and there is probably no extraordinary 
risk in the operation, nor in puncturing the membranes and 
lateral lobes of the cerebellum with a fine trocar. 

5. Hypertrophy and Sclerosis of the Brain are usually 
mentioned by all writers on diseases of children, but it may 
be noted that the literature of the subject increases very 
slowly, and that writers allude to their own personal knowl- 
edge of it in a somewhat vague manner. The only recent 



484 DISEASES OF CHILDREN. 

addition to our knowledge appears to be that, whereas, in 
former times the nature of the disease was unknown, of late 
years the condition has been definitely described as due to 
an increase of the neuroglia of the brain — to the disease 
therefore which is now called sclerosis. There is no reason 
why both diffused and disseminated sclerosis should not 
occasionally occur. As stated elsewhere, children occa- 
sionally come under notice with symptoms very closely 
resembling those of disseminated sclerosis in the adult. 
But the actual demonstration of the condition by post- 
mortem evidence is scanty in the extreme, and it is not 
certain that it has occurred. In reading over the cases of 
hypertrophy of the brain recorded, one cannot but be 
struck with its close association with a rachitic skeleton ; 
and inasmuch as a thick skull is found in rickets, one is 
doubtful in some cases, in the absence of actual weights, 
how far the large head was due to actual increase of brain 
matter, how far to the size of the skull. Gee has recorded 
two cases,* however, in which the brain was very heavy. 
A boy aged 2^, highly rickety, and suffering from con- 
vulsions ; the body weighed 17^ lbs., the brain 59 oz. ; 
the average at this age being 38.71 oz. A girl of the same 
age, and also rickety, weighed 15^2 lbs., and the brain 42^ 
oz., the average being 34.97 oz. In both cases the brain 
appeared to be perfectly healthy. Dr. Hilton Fagge alludes 
to one case that came under his own notice, and to six 
others under Dr. Fletcher Beach, of the Dareuth Asylum. 
Dr. Beach has found a uniform granular appearance in the 
white matter under the microscope, with nerve-cells scat- 
tered sparsely throughout and an infiltration of the tissue 
with leucocytes. The increase in size was evidently due to 
the large amount of granular matter. Dr. Goodhart is 

* " On Convulsions in Children," St. Barth. Hosp. Reports, vol. Ill, p. 109. 



CEREBRAL HEMORRHAGE. 485 

disposed, while calling attention to its possible existence 
and to the necessity of closely investigating all curious 
brain symptoms that occur in cases of rickets or elsewhere, 
to emphasize the remark of Dr. West, made long ago, but 
still true, " I am not sure that an undue importance has not 
sometimes been attached to it, as though it were of much 
more common occurrence than you will find it to be in 
practice." The author has not hitherto met with such a 
case. It is said to come on slowly at an early age, and to 
be attended with loss of health, dullness, apathy, and a 
liability to convulsions ; the head seems too heavy for the 
child, and it frequently bores in the pillow. In older chil- 
dren the gait may be feeble or tottering. The disease may 
run a course of years ; one of Dr. Beach's patients was six- 
teen. It ends by some intercurrent pulmonary affection, 
by gradual exhaustion, etc. 

6. Cerebral Hemorrhage is a rare disease, but it is nev- 
ertheless an important one. It may be meningeal or intra- 
arachnoid (the two cannot be separated), or into the sub- 
stance of the brain. The former is most probably more 
common than it has been proved to be upon the post- 
mortem table, for the reason that in many cases there can 
be no obstacle to recovery, and looking to the many possi- 
ble causes of such a condition in early life, it is very likely 
indeed that some, if not many, of the chronic thickenings, 
cysts, and other affections of the membranes, which are 
denominated inflammatory, may have their origin in sur- 
face hemorrhage. It cannot, however, be said that this is 
certainly so, except in a few instances. 

Meningeal hemorrhage may be of all degrees of severity, 
from mere capillary ecchymosis to a diffused layer of clot 
of some standing. It appears to be more common in new- 
born children, the reason for this no doubt being the dis- 
advantageous conditions of the circulation which exist 
4i 



486 DISEASES OF CHILDREN. 

during delivery, whether natural or instrumental, and the 
circulatory changes that take place within a short time of 
birth. Of other conditions, whooping-cough and severe 
purpura will at once occur to any one as liable to lead to 
it, and cases are on record due to both these diseases. 
Thrombosis of the sinuses, the various abnormal blood 
conditions met with in the exanthemata and other fevers, 
are also noticed as being occasional causes. 

It cannot be said to have any symptoms which are path- 
ognomonic, but in any case in which its existence is ren- 
dered probable a sudden coma or collapse, a weakness of 
the limbs on one side or the other, perhaps a convulsion 
also, might lead to a guess that something of the kind had 
happened. 

It might fairly be hoped that by quietude and careful 
feeding, absorption of the clot would take place and re- 
covery ensue. But for such a case it may be well to say 
that although the prognosis might be very favorable, there 
is abundant evidence in adult life to show that meningeal 
extravasations are slow in disappearing completely — pig- 
ment and thin layers of lymph are found many months after 
extravasation of this kind. Consequently the greatest care is 
necessary to preserve the patient from excitement or active 
brain work for a considerable time after such an occurrence. 

Hemorrhage into the substance of the brain has in very 
rare cases been due to atheroma of the vessels, but it is 
commonly due to embolism from heart disease, and the 
hemorrhage is commonly preceded by the formation of an 
aneurism. 

The symptoms would be those of apoplexy in the adult 
— viz., sudden onset of right hemiplegia with more or less 
coma, or some general paralysis if the plug should block 
the basilar artery, instead of the more usual seat of left or 
rieht internal carotid at the base of the brain. 



CEREBRAL HEMORRHAGE. 487 

The diagnosis would mostly depend upon the evidence 
of the existence of heart disease, or of some reason for the 
formation of clots on the valves or in the cavities — either 
from recent rheumatism, or chorea for the valves ; or scar- 
latina, or typhoid, or other exhausting illness for dilatation 
of the left ventricle. It will often be difficult to say whether 
the embolism remains as such, and the paralysis is embolic 
only ; or whether an apoplexy has followed it. 

The prognosis is grave in all cases from valvular disease, 
because the embolism most commonly occurs, or at any 
rate produces such severe symptoms, in the worst cases 
only. The valvular disease is likely to be of fungating or 
ulcerative form ; the patient to be febrile and anaemic ; very 
likely with albuminuria from a dilated ventricle, because 
hemorrhage following upon embolism denotes extensive 
softening, and, in the rare cases due to atheroma, because 
the disease has been usually basilar and the hemorrhage 
into the pons or its neighborhood. Supposing that hemor- 
rhage could be excluded and the case diagnosed to be one 
of embolism only, probably a slight distinction might be 
made in favor of clots discharged from a dilated ventricle. 
Probably these, not having an inflammatory origin, are less 
likely to provoke a local inflammation in the vessels in 
which they lodge than are those which are discharged from 
an inflammatory focus on the valve. 

Absolute rest ; ice or cold lotions to the head ; the bowels 
should be kept active, and food administered carefully. 
Here, too, as in adults, the lungs should be watched and 
preserved from the accumulation of mucus at their bases, 
by attending to the position of the child which should be 
frequently changed from side to side. 

In the more common cases of apoplexy, due to valvular 
disease, one- or two-grain doses of quinine should be given 
if there be any pyrexia, and the heart's action should be 



488 DISEASES OF CHILDREN. 

quieted and sustained by bromide of potassium, belladonna, 
or digitalis. 

7. Thrombosis of the Cerebral Sinuses. — In the larger 
number of cases the lateral sinuses only, one or both, are 
affected. The longitudinal sinus also, but rarely. In these 
cases the lesion is due to disease of bone, and in infancy 
chiefly to disease of the ear, whilst the inflammation of the 
petrous portion of the temporal bone causes phlebitis of the 
petrosal or lateral sinus. But there are also many other 
cases, and the majority children under two years of age, in 
which no such causes can be found. In these it has been 
noticed that the clot is less in the lateral than in the longi- 
tudinal sinus. 

Virchow originally pointed out that not only in the 
cranium but in the pelvic veins and the veins of the lower 
extremity, the blood current is at times so slow as to render 
spontaneous coagulation a risk, and in the longitudinal 
sinus of the cranium the shape of the channel, and the fact 
that the tributary veins run into it in a direction against the 
current, have always been considered as in favor of throm- 
bosis. Thus, when no cause has been found for the coagu- 
lation, as has often happened, it has been assumed that the 
coagula are due to these natural conditions telling disadvan- 
tageously upon an unnaturally feeble current. 

A very good division, therefore, of the cases of thrombosis 
of the cerebral sinuses is that given by Steiner, into exhaus- 
tive and inflammatory. The exhaustive essentially concern 
the longitudinal sinus, and is found in any feeble depressed 
conditions, such as cholera infantum, scrofula, rickets, etc. 
The inflammatory form affects chiefly the basal sinuses, and 
can be traced to disease of the ear, and injuries or local 
inflammation of the cerebral membranes. 

Symptoms. — These are very obscure, and the thrombosis 
is found by accident at the autopsy. Lethargy, stupor, or 



INFANTILE PARALYSIS. 489 

coma are the more common — epistaxis, occasionally result- 
ing from plugging of the longitudinal sinus. Any obstruc- 
tion in the cavernous sinus — which, however, is very rare — 
might be detected by the morbid appearance of venous 
congestion visible by the ophthalmoscope at the fundus oculi. 

Treatment. — The exhaustive form is one for prevention 
rather than cure. The risk is to be remembered in feeble 
infants, and wine and good food administered. So also is 
the inflammatory form one for prevention, seeing that it 
arises so often from disease of the temporal bone, and that 
this follows upon discharge from the ear. Much may be 
done by paying careful attention to cleanliness and the 
application of antiseptic collyria in cases of this kind, and 
— should any evidence of disease of the bone unfortunately 
arise — timely surgical interference by an incision over the 
mastoid and trephining may possibly give an outlet for foetid 
material and thus avert a fatal result. 

8. Infantile Paralysis. — The alpha and omega of the 
student's knowledge on this subject comprises often no more 
than a few facts about what has from time immemorial 
received the name of infantile paralysis. But there are at 
least several other forms of paralysis which, if not quite so 
disproportionately infantile, are nevertheless common in 
childhood, and deserve to be reckoned among the diseases 
of children. And others, again, though occurring more 
often in adults than in children, which must be enumerated 
as occasional occurrences, lest being unexpected their import 
may be mistaken. No scientific classification of these will 
be attempted, because our knowledge of their causes, or 
rather of the lesions by which they are produced, is still 
very meagre. Some are due to cerebral, others to spinal 
lesions ; some, probably, to no lesion at all. They will be 
taken as they most frequently come under the notice of the 
student. 






490 DISEASES OF CHILDREN. 

a. Infantile Palsy, as the most familiar form of the dis- 
ease, may be taken as a starting-point. " Essential paralysis " 
it is sometimes called, because at one time it was supposed 
to be due to a disease of the muscle. Some still contend 
that a muscular lesion is the primary fault, and that the 
nerves or cord undergo subsequent changes from an ascend- 
ing neuritis. But the generally received doctrine is that 
the paralysis is due to a primary disease of the nerve-cells of 
the anterior cornua of the spinal cord. It is a disease which 
is not confined to infancy, but so largely preponderates 
then that 154 cases, out of a total of 205, occurred between 
the ages of six months and two years. It has been noticed 
within a few days after birth. (Ross.) It is liable to affect 
the healthiest children, attacking either sex equally, and is 
said to be more common in the summer months. The 
author has sometimes thought that a rheumatic parentage 
might have something to do with its production, but nothing 
is known regarding this. Duchenne states that he has not 
been able to associate it with nervous disease of any kind 
in the family. Of exciting causes, exposure to cold is often 
mentioned, and of this the following is a striking instance : 

A male child of five months old was sent to Dr. Goodhart 
by Mr. Richardson, of Croydon, with this history. Its father 
had suffered from rheumatic fever badly. The child was 
taken out in October, when six weeks old, and kept out on 
a cold day, for two and a half hours, late in the afternoon. 
It was brought home " perished " with cold, and with its 
eyes drawn up, and snatching its breath. It was in a burn- 
ing heat all night, and kept starting as if falling. It was 
unconscious for a week or more, and was continually moan- 
ing. It gradually recovered from the coma, and at the end 
of a fortnight its right arm was found to be quite useless. 
This had recovered somewhat since, but was still useless 
in great measure. 



INFANTILE PARALYSIS. 49 1 

Symptoms. — These will be best illustrated by a case. The 
one already given is a typical one, but another may be 
added. 

A boy ten months old went to bed quite well one night, 
and when taken up the next morning was " paralyzed all 
over " — that is to say, his head dropped about, and he had 
no power of sitting or moving — the trunk muscles being 
paralyzed. He was also feverish, but no teeth were being 
cut at that time. The leg was noticed to waste afterwards, 
and use in it was never regained, although the general pa- 
ralysis improved. The child was brought to the hospital two 
months after the attack. His right leg was mottled from 
cold ; it hung flaccid from the pelvis, and was perfectly 
powerless. On passive movement, it could be put into 
almost any position, the hip being unnaturally lax, without 
any pain. In all other respects theboy seemed quite healthy. 
Dentition had progressed rapidly, and he was not rickety. 
The muscles failed to respond to the Faradic current, but 
reacted slightly to galvanism. 

Such is the short and usual history of infantile paralysis. 
A healthy child sits in a draught, gets cold, cuts a tooth — 
anything possibly, nothing certainly — and becomes feverish, 
fretful, is perhaps convulsed or semi-comatose, and is shortly 
found to have general paralysis. The child often cries when 
it is moved about, or when its limbs are touched ; but it is 
doubtful whether this be due to pain or merely to the dis- 
turbance when it is not feeling well. In a day or two the 
fever passes off, and with it, perhaps, some of the paralysis ; 
leaving a leg or an arm, or both legs, or perhaps one side, 
or perhaps only this or that group of muscles, completely 
paralyzed. If the child be taken to the doctor he recognizes 
at once the dangled limb, and finds more or less complete 
absence of response to the Faradic current ; more or less 
qualified action with the galvanic current, but no alteration 



492 DISEASES OF CHILDREN. 

of sensation. This, however, is hardly a common hospital 
experience. Three or four months Usually elapse before 
medical aid is sought. By that time the limb is much 
wasted ; the skin is often livid with the sluggish circulation 
consequent upon the reduction of temperature; all the soft 
parts are flabby, and the electric irritability to any form of 
current is quite destroyed. Perhaps years elapse, and then, 
in addition, there is dwarfing of the affected limb from 
diminished growth, and sometimes deformity from the 
unbalanced action of those groups of muscles which are not 
paralyzed. Deformity is, possibly, less common in infantile 
than in other forms of paralysis, excepting perhaps that of 
talipes equinus and varus, because it so frequently happens 
that the entire limb is affected. 

The characteristic features of the disease, then, are : The 
initial fever, the sudden onset of motor paralysis, the rapid 
loss of electric contractility in all those muscles which are 
severely affected, followed by their progressive atrophy, and 
the gradual restoration subsequently of all those muscles in 
which the electric contractility is preserved at the end of 
the first fortnight. There is no progressive character about 
the disease — the mischief appears to be worked at once and 
then ceases. The affected muscles atrophy, but no fresh" 
ones are attacked ; and while perfect recovery is perhaps 
seldom seen, a partial recovery is the rule. 

All reflex actions are lost in the affected muscles, to be 
regained, however, as the muscles recover themselves. 
Sensation is unaffected. 

As regards the fever at the onset, Duchenne states it to 
be usually, but not invariably, present — of seventy cases it 
was absent in seven. But no negative statement of this 
kind is of great value when such young subjects are con- 
cerned. Moderate fever is so often unappreciable except 
by the thermometer. 



INFANTILE PARALYSIS. 493 

The seat of the paralysis is very variable. The following 
table is from Duchenne's L Electrisation Localise e, as given 
by Dr. Poore. 

In sixty-two cases there were : — 

5 of general paralysis. 
9 of paraplegia. 

1 of hemiplegia. 

2 of crossed paralysis. 

25 of paralysis of right leg. 

7 of paralysis of left leg. 
10 of paralysis of right or left arm. 

2 of lateral paralysis of the upper limb. 

I of paralysis of trunk and abdomen. 

In the author's cases the right leg was paralyzed in six ; 
the left leg and left arm once each ; the right arm twice ; the 
distribution was hemiplegic once, general twice ; in both 
legs three times ; in five out of sixteen cases the pain at 
onset appears to have been pronounced. 

Morbid Anatomy and Pathology. — This form of paralysis 
has been supposed to be due now to muscular disease, now 
to disease of the nerve-endings in the muscles, or to disease 
of the efferent trunks. But all the examinations of recent 
years have gone to show that there is an actual disease, 
inflammation it is called, of the spinal cord. The affected 
muscles undergo rapid fatty degeneration, but only in con- 
sequence of irreparable destruction of the motor areas in 
the cord. The changes which occur are as follows : In the 
earlier stages small foci of softening are found in the gray 
matter of the anterior cornu. They are usually of small 
size, run in vertical streaks, and are particularly liable to 
attack the cervical and lumbar enlargements. They may be 
of reddish color, and under the microscope show an increase 
of the capillary network, and oedema of the vessel-walls, with 
42 



494 DISEASES OF CHILDREN. 

a nuclear growth in more or less profusion. In the later 
stages, as might be imagined from what is known of the 
laws of pathological changes, the appearances are those of 
the so-called sclerosis — that is to say, the connective tissue 
between the nerve-fibres undergoes increase and thickening, 
and the nerve-cells and nerve-fibres become atrophied. The 
common appearances in old cases of infantile paralysis are 
diminution in size of the affected part of the cord — diminu- 
tion of the one anterior horn of gray matter as compared 
with the other, and shrivelling and over-pigmentation of the 
nerve-cells. Sometimes the corpora amylacea of nerve de- 
generation are found. The nerve-trunks related to the 
affected limb are smaller than those on the other side, and 
the muscles are atrophied, and, in many cases, replaced 
almost entirely by fat. 

Finally, it is worth remark that the bones of the affected 
extremities are stunted, and that, not in proportion to the 
extent of the paralysis, i. e., to the want of movement. Very 
slight paralysis may be attended with much shortening, and 
in extreme paralysis the affected limb may be no shorter 
than its fellow. 

The disease which produces all this mischief in the cord 
is an acute anterior polio-myelitis, or an acute inflammation 
of the motor cells; and this opinion is based upon all the 
hitherto recorded microscopical examinations of the spinal 
cord. Some have discussed whether the change is in the 
nerve-cells or in the interstitial matter surrounding them, 
but this is a matter upon which we have no evidence, and 
which is not of importance. In one or two cases the ap- 
pearances have been those of a small extravasation of blood 
in the cord, rather than an inflammatory condition. 

At the same time, it must also be remembered that the 
cases examined are by no means many, and the majority 
of these have been procured many months, in most many 



INFANTILE PARALYSIS. 495 

years, after the lesion has occurred. Only in one or two 
has the disease been so recent as two months after the 
onset of the paralysis. In saying this it is by no means 
wished to call in question the facts recorded, but only to 
impress more strongly that we are as yet quite in ignorance 
of the essential cause of the disease. Even allowing the 
morbid anatomy to be as stated, we yet require to know 
what leads to the disease in the spinal cord — it is still to 
clinical data that we have to appeal in great measure to 
support any view of its nature. Now these data are of two 
kinds, and seem to point in different directions. 

1st. One class of cases is attended with fever, often high, 
and the paralysis is at its first onset a general paralysis, and 
often associated with pain. This class furnishes a conclusive 
proof of a central nervous affection, for a general paralysis 
can hardly be anything else. It is impossible to suppose 
any sudden general affection of the muscles or of the peri- 
pheral endings of the nerves. It would seem not so very 
improbable that this initial fever might be the essential 
disease, and the nervous affection the result of it. Acute 
febrile conditions are dangerous to the vitality of all tissues, 
but most of all to the nervous system of a rapidly develop- 
ing infant. All acute febrile disturbance in infancy is liable 
to be ushered in by a convulsion, or, what is still more 
common, by the rigid spasm of arms and legs, fingers and 
toes, which goes by the name of tetany. This is a not 
infrequent history of the onset of a case of infantile paralysis, 
and there is no great improbability in the hypothesis 
that the paralysis is due to some acute febrile disturb- 
ance. But it may, perhaps, be deemed curious that the 
febrile state should spend its force exclusively on the nerve- 
cells of the anterior cornua, and be, indeed, but partially 
distributed among them. To such an objection it might in 
part be replied, that the nervous affections of childhood are 



496 DISEASES OF CHILDREN. 

largely motor disturbances. Children do not complain of 
pains and aches with anything like the frequency that 
adults do. Convulsions, spasm, chorea, etc., replace pain 
in great measure, and one would therefore suppose that, 
given a cause, acting equally on all parts, those used most 
and most sensitive would most show the results of the 
working of the cause ; and in childhood, therefore, the 
motor-cells would be likely to fail first. But it is unneces- 
sary to adopt this line of argument, because a better is 
at hand — viz., that the pyrexia does not act solely on the 
anterior cornua, it acts upon the entire cord, often upon the 
brain and cord, and thus we have at the onset coma or a 
general paralysis and some pain. If this be the case, the 
only peculiarity that needs explanation is the partial distri- 
bution of the disease, as evidenced by the subsequent symp- 
toms and also by the morbid anatomy. But this is quite 
explicable by what we know of the physiology of the cord. 
In the first place, the cause of the affection being a very 
transitorily acting one, much of the original paralysis gen- 
erally clears up, and thus in the end only a small lesion in 
the cord is discoverable. Then the paths of sensory impres- 
sions are not strictly localized, like the motor. How far 
more common it is to find motor paralysis at any time of 
life, than it and anaesthesia combined; there may be a com- 
plete loss of motion from even diffused changes in the cord, 
and yet no anaesthesia, a fact that can only be explained by 
assuming, what has indeed been proved by experiment, that 
the sensory currents filter through the cord, rather than run 
in streams. Minute lesions in such a case would naturally 
be more difficult to detect when we have no immediate 
opportunity of examining the diseased structures, and are, 
indeed, mostly unable to do so until many months or years 
after the original affection. 

Some hypothesis of this sort takes away the chief difficulty 



INFANTILE PARALYSIS. 497 

in understanding the disease, or, at any rate, a difficulty 
which is a stumbling-block to many — viz., the impossibility 
of giving any satisfactory suggestion why, as it were with- 
out rhyme or reason, a few motor cells should seem to be 
picked out here or there, while the rest of the cord go scot 
free. It is probable that what seems so apparent is never- 
theless not the real state of the case, but that there is a 
general acute disturbance, inflammation it may be called 
provisionally, of the entire cord, which rapidly subsides as 
its cause, pyrexia, subsides, leaving here and there some 
parts shattered by the storm. The parts most conspicuously 
affected will naturally be those in which the motor nerve- 
cells largely congregate, for not only is the motor lesion 
concentrated while the sensory is not, but the motor func- 
tion that is destroyed corresponds with an absolute loss of 
nerve-centre, and this entails other secondary consequences 
of trophic and atrophic character, which must add to the 
primary lesion. It may also be added that it is by no means 
uncommon to find some evidences of mental weakness, 
approaching in one direction or another to imbecility, in the 
subjects of infantile paralysis, though, perhaps, they occur 
less often than one might think, if we carefully distinguish 
between the spinal and cerebral paralyses of childhood. 
This group of cases confirms then, from clinical data, the 
opinion derived from pathological observation, that the spinal 
cord is at fault. Before parting with the subject, the student 
may be reminded that, although we call this disease infantile 
paralysis, yet there is an exact counterpart of it in adults, 
called acute atrophic spinal paralysis, a rare disease, but 
one which is sometimes seen in the form of general paralysis 
of sudden onset and sudden recovery, for the most part 
leaving only groups of muscles paralyzed here and there. 

2d. There is, however, another group of cases, in which 
the evidence of a primary spinal affection, although such is 



49$ DISEASES OF CHILDREN. 

assumed to be existent, does not appear to be by any means 
so conclusive. There is no evidence of any general paraly- 
sis, none, perhaps, of pain. All that can be told of the case 
is that a loss of power in this limb or that has been noticed 
quite suddenly. It often happens that we are told that the 
child was left playing on the floor for some time and when 
taken up was found to be affected, or that it went to bed 
well and woke up paralyzed. This is, no doubt, the history 
which is obtained at first in many undoubted cases of ante- 
rior polio-myelitis, and to that affection all these cases are 
now uniformly ascribed. Nevertheless, some of them bear 
so much resemblance to some cases of facial palsy, as seen 
in adults, that the question of local and not central origin 
may occasionally be entertained. There is no class of nerve 
cases more uniformly associated with a definite onset than 
Bell's palsy, as it is called — paralysis of the portio dura on 
either side — and its history is this : The patient, a little 
below par, perhaps, is exposed to wet or cold; very fre- 
quently it can be stated that, at a definite time, he sat in a 
draught, with a stream of cool air playing on his cheek. 
The history is so constantly one of this kind, that it seems 
to be impossible to associate the symptoms with any central 
lesion, hardly possible to believe otherwise than that some 
local change must have been wrought in the nerve, as it 
lies in its somewhat exposed situation on the side of the 
face or crossing the roof of the tympanum. What are the 
symptoms ? They are emphatically sudden onset, rapid 
loss of Faradic contractility, and more or less complete 
recovery in the space of a few weeks or less. And if it be 
true that such a cause can produce such a result in adults, 
there is no improbability in supposing the existence of some 
similar affection in children. It is curiously seldom that 
facial paralysis is found in childhood, except under other 
circumstances presently to be mentioned. But in this per- 



INFANTILE PARALYSIS. 499 

haps we may see in part an illustration of the rule, that 
those parts most subject to use or strain are most liable to 
break down ; in part, perhaps, it is explained by the relative 
degree of liability to exposure and injury which various 
parts suffer at differing periods of existence. The limbs in 
children are all movement, uncontrolled movement, and 
exposed in many cases constantly ; as yet the facial nerve, 
though it is no doubt exposed now as it is later on, has not 
become subject to the constant strain involved in the ever- 
varying phases of expression. Thus is explained the fact, 
that children are liable to suffer from local paralysis of limb 
rather than of face; and it seems possible that, even though 
the nerves involved be mixed ones, yet the sensory function, 
suffering less, might be difficult of detection at this age, and 
the entire trouble thus pass for motor. 

Dr. Goodhart is quite prepared to think with Dr. Buzzard, 
that the hypothesis of a peripheral neuritis better accords 
with the clinical history of some cases of infantile paralysis 
than does that of a central lesion. But Dr. Buzzard goes 
beyond this ; he writes : " It is highly probable that a cer- 
tain number of cases of so-called infantile paralysis are 
examples of multiple neuritis. I am much disposed to 
think that in the cases of infantile paralysis which make 
unexpectedly good recoveries after very long delay, the 
lesion may have been in the nerve trunks and not in the 
anterior ganglia of the cord." 

These cases are not common, but the following is a 
striking one : — 

Gertrude S., three and a half years, was admitted into 
the Evelina Hospital in December, 1883, for a general 
paralysis, which had existed for six months or more. It 
had come on after no definite illness, and the first thine 
noticed was that she frequently stumbled and fell, and next, 
that in feeding herself, she would use one hand to support 



500 DISEASES OF CHILDREN. 

the other. Latterly she had been unable to use her hands 
at all, and when not fed by any one she would bend her 
head down to her plate. Two months before her admission 
she had been taken to the seaside, but returned in a state 
of complete helplessness. 

When admitted she was unable to stand or move her 
extremities. When placed in a sitting posture she would 
perhaps remain so, but had a' tendency to roll over to her 
right side. She was unable to move either legs or arms, 
and the movements of the chest were extremely shallow. 
The muscles of her extremities were flabby and wasted, 
and gave no response either to Faradic or galvanic currents. 
Notwithstanding, she was assiduously galvanized, but with- 
out any very obvious result for many months, during which 
time she took and recovered from measles, although for 
many weeks after this there was extensive consolidation of 
the bases of both lungs, due, as Dr. Goodhart supposed, 
to the existence of atelectasis from the combined influence 
of the catarrh, of the measles, and the impaired move- 
ments of the chest. She was in the hospital altogether 
eleven months, and during the latter part of her stay she 
decidedly improved. The improvement first showed itself 
by her being able, with some effort of her shoulder mus- 
cles, to throw her forearms across her chest ; and then in 
the regained power of clumsily moving her thumb and fin- 
gers, and latterly she could feed herself, and was just able 
to crawl around her cot by holding on to the rails. But 
the progress was so slow that the author was not very 
sanguine of her future when she left. She was brought to 
him for some other ailment six months later, and by this 
time she was comparatively well. She had gradually im- 
proved; three months after leaving the hospital she had 
begun to walk about, and she could now walk and run 
about fairly well, though treading on the sides of her feet, 



INFANTILE PARALYSIS. 501 

and thus wearing the heels of her shoes into a keel. The 
muscles of the palms of the hands were still very flabby, 
and the flexors of her fingers moved badly. Her move- 
ments are now described by her mother as natural. 

The deformities that ensue will depend in great measure 
upon the muscles that are affected ; the leg muscles being 
prone to suffer, and frequently those of the front of the tibia, 
talipes equinus and equino varus are the more common. 

Diagnosis. — Perhaps it may be thought that there are not 
many diseases for which an anterior polio-myelitis is apt to 
be mistaken, and to a careful examiner this is true ; never- 
theless the paralyses of infancy and childhood often present 
difficulties from the very fact that the subjects of the disease 
are unable to give any account of their sensations, and that 
they are brought for treatment perhaps months after the loss 
of power was first noticed. There are several disorders of 
movement in childhood which have to be considered and 
eliminated in making a diagnosis ; and first of all may be 
mentioned paralysis due to pressure and nerve-stretching. 
The author has several times been in doubt between in- 
fantile paralysis and an affection of this kind. A young 
child is left playing, perhaps on the hard floor, with but little 
power of changing its position, and with its nerves unpro- 
tected by the ossified prominences which seem made to 
shield them in later years. There is, at any rate, nothing 
improbable in the assertion that it was left in health and 
taken up paralyzed. In the upper extremity, nerve-stretch- 
ing, taking the place of direct pressure, may readily lead 
to similar results. Supposing there be a doubt about the 
case, the points to be attended to are alterations of sensa- 
tion, incompleteness of paralysis, and little, if any, disturb- 
ance of the normal electric actions. The previous history 
must also be taken into account, although this is liable to 
mislead in any case. 



502 DISEASES OF CHILDREN. 

Other cases come as paralysis, particularly of the arm, 
which turn out to be due either to injury or disease of the 
joint. Injury is very common at the shoulder-joint; acute 
disease of the head of the bone and cartilage is common at 
the hip; and for elbow and knee there is a local periostitis, 
not at all uncommon and generally syphilitic, which may 
lead to immobility of the limb. To remember the possi- 
bility of these is to avoid any error, for all these lesions are 
prominently painful. An examination of the joint gener- 
erally indicates a difference between the two sides, and for 
the syphilitic affection there is usually a considerable 
amount of swelling just above the joint; and, of course, if 
we have to go farther, and apply electrical tests, the pres- 
ence of undiminished electrical excitability should settle 
any occasional difficulty there might be. 

Rachitic paralysis is of the same nature. There are few 
things more common than to have infants brought for pa- 
ralysis of the legs, and to find that they are rickety. Rachitic 
children have very tender bones. They are not only soft, 
but they are actually tender, and such children constantly 
cry when they are handled hurriedly or roughly. But 
here, again, the existence of rickets should be a diagnostic 
safeguard, and the persistence of pain makes the solution 
of the case easy. 

Infantile paralysis will sometimes need to be distin- 
guished from many other paralyses as they occur in chil- 
dren, and perhaps chief of these is the paraplegic form — 
from paralysis due to compression of the spinal cord. In 
this the paraplegia is often very incomplete; it may be 
associated with rigidity, and the reflexes, in place of being 
abolished, are manifestly exaggerated, while the muscular 
atrophy is replaced by mere flabbiness. Some affections of 
the bladder may also help one to a conclusion, although the 
irregularities of infants in this way tend to obscure an other- 



INFANTILE PARALYSIS. 503 

wise helpful symptom. The spinal column should, how- 
ever, in all cases be carefully examined, as spinal caries and 
curvature may occur in babies of but a few months old. 

Hemorrhage into the cord (haemato-myelia) appears 
sometimes to occur, and a diagnosis might indeed be 
exceedingly difficult in some cases. It might be expected 
to be less localized in its effects, and thus rather to produce 
the symptoms of central softening, with its anaesthesia, its 
tendency to bedsores, paralysis of sphincters, and exagger- 
ated reflexes. 

Late cases may also be confounded with the atrophic 
stage of pseudo-hypertrophic paralysis, or progressive 
muscular atrophy. The latter, however, is rare. In late 
cases of infantile paralysis the atrophied muscles may be 
replaced by fat, and pseudo-hypertrophic paralysis is fol- 
lowed by extreme wasting of the muscles. The history 
must, in these cases, be relied upon. The slow progress 
of the pseudo-hypertrophy, the characteristic walk, and 
slow atrophy with long-retained electrical reactions, must 
serve in most cases to distinguish them. 

Before quitting this part of the subject, and as allusion 
has already been made to the occasional occurrence in 
adults of a similar affection, and now again to the occa- 
sional appearance of progressive muscular atrophy in chil- 
dren, it seems worth while, from a diagnostic point of view, 
to draw attention to the interesting contrast that exists be- 
tween infancy and adult age as regards the diseases of the 
spinal cord to which the two epochs are liable. 

Acute spinal paralysis is common in children, it is most 
rare in adults ; chronic spinal paralysis is common in adults 
and very rare in childhood. Looking a little further into 
the matter we can see that this is just what might be ex- 
pected. Children are subject to sudden and violent febrile 
attacks, and their tissues are constantly in a state of change 



504 DISEASES OF CHILDREN. 

and development. Adults are far less liable to the exciting 
cause, and their tissues have reached such a condition of 
stability that they do not take offence so readily, but when 
they are disturbed they recover more tardily. On the other 
hand, the conditions which lead to chronic spinal paralysis 
and its consequent muscular atrophy are probably quite 
different; they are in great measure degenerative, or en- 
tailed by various local diseases of blood vessels, capillary 
hemorrhages, and so forth, which are not likely to be found 
in young people at the time of life with which we are now 
dealing. At the same time we must be prepared occasion- 
ally to find such a case even in childhood. 

Prognosis. — Infantile paralysis but rarely threatens life, 
although complete recovery is the exception. Ross states 
that if the Faradic contractility of some muscles and nerves 
be diminished at the end of five days, and abolished during 
the course of the second week, these will remain perma- 
nently paralyzed. The loss of power will, at any rate, be in 
proportion to the completeness of the loss of Faradic irrita- 
bility ; but so long as there is any reaction to either current, 
so long some restoration of motor power may be expected. 
After many months have elpsed of complete paralysis, a 
fortiori, after a year or two — as often happens in hospital 
cases — any hope of recovery is out of place. We can then 
only look for such amelioration as accompanies the better 
nutrition of the limb which sedulous attention may still 
procure. The editor has lately treated a case in which there 
was paralysis of the left leg followed by complete recovery. 
The patient was seen in the febrile state, the diagnosis was 
made a few days later, and treatment by massage and elec- 
tricity begun early and steadily maintained for several 
months. 

Treatment. — The only question that arises is when to 
commence the application of electricity — that is to say, 



INFANTILE PARALYSIS. 505 

what should be done in the very early stages. It is not 
often that the disease comes under notice at this time, but 
if it should, some advocate resorting at once to electrical 
treatment, whilst others urge that any acute disturbance 
should be allowed time to subside. There is no doubt that 
treatment has to be steered between Scylla and Charybdis 
— those on the one side, seeing the dangers of adding to 
a process they suppose to be inflammatory, advocate rest; 
those on the other insist on the early and hopeless degener- 
ation of muscle if electricity be not resorted to. Now, 
assuming the observations to be correct which have been 
made, and that the early stage of infantile paralysis is one 
of vascularity and cell proliferation in the spinal cord, there 
can be no question that we should not be too ready to 
worry the cord into action. We can conceive that great 
harm may be done in such a case. But we must also 
remember that the initial process, in all probability, rapidly 
subsides, and much of the original affection clears up, and 
when this happens — in the course of five or six days after 
the onset — we may begin to pay attention to local treat- 
ment. Till then administer such things as control the 
circulation — aconite, ergot, digitalis, and iodide of potassium 
being the chief. Half a grain of iodide of potassium with 
a drop of tinct. digitalis may be given every two or three 
hours, or if the fever be severe, half a drop of tincture of acon- 
ite every hour for a few hours at a time. The iodide may be 
replaced by a grain of hyd. c. cret. administered night and 
morning, or a local inunction of mercurial ointment may 
be applied over that region of the cord which corresponds 
to the paralysis. Cold baths, ice compresses to the spine, 
and so on, would also be advisable, in such cases as they 
might respectively seem suited to. In the later stages two 
results may be aimed at — getting some repair in the spinal 
cord, and keeping the muscles in a good state of nutrition. 



506 DISEASES OF CHILDREN. 

For the first object electricity is usually advised, galvanism 
being applied either to the muscles or to the spine. Erb 
recommends that the poles of the battery be attached to 
large sponges, one of which is applied over the supposed seat 
of disease behind, and one on the abdomen in front, and 
thus a gentle current is transmitted through the cord. He 
thinks little of the value of the peripheral application, but 
it is the one more usually adopted. There could hardly be 
any objection to applying both methods. In the application 
of electricity to young children, however, there is a great 
difficulty. The sensation is a strange one, and frightens 
them ; it must therefore be administered with great caution 
and patience, the weakest currents being used at first and 
for some time, in the hope that the stronger may be more 
gradually applied. But in addition, or rather before all 
things, plenty of bathing and rubbing to the muscles by the 
hand is quite as useful in its own way, and quite as essen- 
tial as the application of electricity, and should be practiced 
frequently and patiently. For this the hand should be well 
oiled and the part rubbed and shampooed gently for a 
quarter of an hour twice a day, and when two or three 
weeks have passed by the child should be encouraged to 
make what use it can of the limb. For the application of 
shampooing, or massage as it is called, a little common 
sense forms the best education. The purpose is a gentle 
yet brisk and thorough stimulation of the circulation 
and general nutrition of the skin and muscles by passive 
movements. Patience and a little practice will soon make 
a nurse or mother sufficiently expert in the finger-tip 
kneading requisite to act upon the deeper as well as the 
more superficial groups of muscles. Another important 
point is keeping the limb warm. A notable characteristic 
of such parts is their lividity and coldness. They should 
be enveloped in the warmest wraps and, in very young 



HEMIPLEGIA. 507 

children, in cotton wool. Dr. Marshall recommends two 
stockings quilted together and filled with bran, which is 
heated, for maintaining the warmth of the limb. 

In the various muscular failures, the action of antagonizing 
muscles, so far as is possible, should be controlled in some 
way by aiding the weaker muscles by strapping, or band- 
ages, or india-rubber, always remembering that the counter- 
vailing power must be applied so as not to impede the 
voluntary action of the muscles in any way. But for 
details of this treatment the reader must be referred to works 
which specially treat of the subject. 

b. Hemiplegia. — When a child with loss of power in its 
arm or leg is brought for advice, there is a tendency in the 
mind of the beginner to assume that this is due to infantile 
paralysis. But, according to the author's experience, it is 
not unlikely to prove on examination to be some other form 
of paralysis than an anterior polio-myelitis, for hemiplegia 
or monoplegia of cerebral origin is not uncommon. 

Causes. — Hemiplegia in an adult is mostly due to apo- 
plexy from atheromatous vessels, to embolism, or to syphil- 
itic thrombosis. In childhood, however, we can exclude 
atheroma, and of syphilitic disease very little is known 
except as a cause of meningitis. It is unwise to go so far 
as to say that syphilitic disease of the vessels is not often 
present. More investigation is wanted in this direction ; 
one of the author's own cases came on after snuffles, and 
Dr. Abercrombie, in a lecture on hemiplegia in children, 
alludes to several cases in his series of fifty which suggested 
such a possibility. It is possible that collateral evidence 
may help to elucidate this matter. If we take into con- 
sideration at the same time with these the group of cases 
to be next described as spastic paralysis, and many of which 
are essentially hemiplegic, we shall find that it is not uncom- 
mon for these children to have a choroiditis disseminata. 



508 DISEASES OF CHILDREN. 

Now Mr. Hutchinson has given reasons for thinking that 
this disease is often syphilitic. We are at present without 
any explanation of this association if we except the vague 
one of some generally distributed inflammation of the 
nervous tissues ; and it seems possible that some cases, at 
any rate, are of syphilitic origin. The author thinks, further, 
that some cases of spastic paralysis may be due to a local- 
ized basal meningitis, such as Drs. Gee and Barlow have 
described, and this, too, is known to be associated with 
syphilis. Therefore, on the whole, there would seem to be 
a considerable amount of evidence in favor of a syphilitic 
origin of one group of hemiplegias. From notes of twenty- 
two cases of hemiplegia, the common cause appears to be 
infantile convulsions, or some morbid condition associated 
with them. There was a history of an onset of this kind 
in ten cases. Heart disease will account for others — first, 
by embolism, as in adults ; and secondly, from the changes 
succeeding to some of the exanthemata, more particularly 
scarlatina, measles, diphtheria and typhoid fever. Some 
cases are no doubt rightly attributed to injury, and others 
are due to the growth of tubercle. Tubercle may cause 
even sudden paralysis, but it more frequently produces 
hemiplegic or monoplegic tremors, and weakness of mus- 
cular force of some kind. 

Tubercular meningitis but seldom causes hemiplegia, it 
is more liable to cause local paralysis, the chief example of 
which in frequency and importance is internal squint. But, 
as yellow tubercle, the disease forms masses which, slowly 
and insidiously, undermine parts of vital importance which 
suddenly give way. They more often occur in the cerebel- 
lum, but by no means always ; sometimes the cortex cerebri 
is attacked ; sometimes a large mass may be situated in the 
centre of the corpus striatum. Therefore, if there be any 
history of previous wasting ; any of discharge from the ear, 



HEMIPLEGIA. 509 

or ill-health of scrofulous type, it will be wise to be on 
the watch for disease of tubercular nature. Three of the 
twenty-two cases before referred to are attributed to tubercle 
in the brain. Tumors other than tubercular are also causes 
of paretic conditions, but since these receive separate con- 
sideration there is no need of their further mention here. 

One other cause of hemiplegia, though not a common 
one, still remains — viz., cerebral abscess. Aural discharge, 
with suppuration in the middle ear, may lead to cerebral 
abscess with or without disease of the petrous portion of the 
temporal bone, and abscess may cause hemiplegia. It does 
not usually do so, because the white matter allows of its 
gradual enlargement without symptoms till it gets to the 
surface, which, when it reaches, it inflames and causes death 
by acute meningitis. It has been suggested that some cases 
of hemiplegia own a similar pathogeny to those due to 
anterior polio-myelitis, and it must be admitted that it is 
sometimes very difficult to tell what is the precise lesion. 
The following case illustrates this : — 

Elizabeth T., set. 10, was admitted into the Evelina Hos- 
pital for hemiplegia of the left side. Sixteen months before 
she had been suddenly seized in the early morning with a 
screaming fit, in which she failed to recognize her parents, 
but continually called to her governess not to beat her. 
It was stated that she became paralyzed in the left side, 
and that her head was drawn to the left side. She was 
never convulsed. She was shortly after removed to the 
Gravesend Infirmary, and was there thought to be suffering 
from tubercular meningitis, more particularly because there 
was a strong tendency to phthisis in the family. She 
remained very delirious for a long time, but gradually 
improved as regards the brain power, although the left 
hemiplegia persisted. On admission to the Evelina she 
was a healthy-looking child of hysterical temperament. In 
43 



510 DISEASES OF CHILDREN. 

walking, the left leg was swung forward in a perpendicular- 
like manner and with appearance of considerable effort. 
The left arm was powerless at the shoulder, but she had a 
fair amount of movement at the elbow and of the fingers. 
There was considerable wasting of both arm and leg ; but 
the biceps, triceps and deltoid had suffered more than the 
remaining muscles. The left arm was I ^ inches smaller 
than its fellow, and the left calf I J^ inches. The left limbs 
were colder than the right, and slightly hyperaesthetic. 
All the muscles acted well to the Faradic current except 
the deltoid and the biceps on the affected side ; these gave 
no response. The fundus oculi was natural. 

Lastly, there is hemichorea. To remember its existence, 
as so often said, is to detect it, and thus to eliminate it from 
hemiplegia in ordinary. But it is quite a common thing 
for a girl or boy to be brought for paralysis of one side or 
one arm. The child, it may be, has an idiotic expression, 
and the restless twitch of a finger, a shoulder, or some of the 
muscles of the face or neck, reveal the disease in a momenf. 
With the caution that chorea is a condition in which definite 
embolic paralysis sometimes occurs, we may refer the reader 
to the chapter devoted to chorea for any further informa- 
tion concerning that disease. 

Functional hemiplegia is not often found in children, but 
the author has seen two well-marked cases in boys — of 
which a few details will be given in the section devoted to 
functional affections. 

Gowers has suggested that thrombosis of the veins of the 
cerebral cortex may produce hemiplegia, and although it 
seems unlikely that it should bring about hemiplegia of any 
completeness, Dr. Goodhart has lately seen a case which 
makes him think the suggestion by no means improbable 
for some of the hemiplegic forms of paresis that are met 
with not uncommonly. The case in point was an infant 



HEMIPLEGIA. 5 I I 

of four months old, admitted for convulsions and retraction 
of the neck. The author thought during life that there 
were many momentary spasms or rigidity of the left arm 
and leg. It was ascertained after death that there was 
thrombosis of the right lateral sinus, and the intracranial 
circulation had been so much disturbed that there were 
extensions and peculiar gaps due to softening in the white 
matter of the frontal lobes and elsewhere. There was exten- 
sive suppurative meningitis as well, due in all probability 
to suppuration of the middle ear which existed. But had 
the case been one of less severity, and the child recovered, 
there would have been cysts in the hemispheres, for the 
morbid anatomist in after years to puzzle over and explain. 
Morbid Anatomy. — Very little is actually known about 
many of these cases, but the subject is one of particular 
interest, because, apoplexy of the substance of the brain 
being excluded, one frequent cause in adult life of severance 
of the continuity of the motor tracts is absent ; whilst an 
adequate cause of extensive cortical lesion is present in the 
fact that so many cases appear to originate in consequence 
of convulsions. One cannot but suppose that infantile con- 
vulsions are not unlikely to produce intense cortical conges- 
tion of the brain, and then to lead to meningeal hemorrhage, 
and to produce hemiplegia. If not this, yet they may initiate 
chronic changes in the membranes, which will not only 
thicken them, but will also compress and lead to'atrophy of 
the entire half of the brain. Thus, years afterwards, it may 
happen that a unilateral atrophy of the brain is found, or 
perhaps a large cyst full of serum or chocolate-colored fluid 
and cholesterin. When we find such changes, there is gener- 
ally, from the lapse of time, great obscurity about their origin ; 
but we know, from recorded cases, that such diseases as 
pertussis, which produce sudden and extreme turgidity 
of the vessels of the brain, occasionally cause meningeal 



512 DISEASES OF CHILDREN. 

apoplexy and death. It is, then, a reasonable hypothe- 
sis, that surface hemorrhages of similar origin sometimes 
also start more chronic evils. Further, although syphilis but 
seldom leads to gummata, there is evidence in favor of its 
power to produce meningitis, and if this be allowed, it would 
follow as at any rate not improbable that pachymeningitis 
would sometimes be found ; and, besides these causes, there 
are. all the slow processes, partly hemorrhagic, partly inflam- 
matory, set in action by injuries and by unhealthy inflam- 
mations about the floor of the skull, chiefly about the 
internal ear. 

As regards embolism, one may wonder that it is not more 
common than it appears to be. Heart disease is common 
enough ; but it is to be remembered that whenever apoplexy 
of the substance of the brain is found in young children, a 
careful search is to be made for an aneurism on some branch 
of the cerebral vessels, and for heart disease, which, through 
embolism, is the common cause of the hemorrhage. The 
hemiplegia, which sometimes occurs after the exanthemata, 
is probably embolic, and due either to. some endocardial 
inflammation, or possibly to the detachment of clot which 
has formed in some pouch of a dilated ventricle, owing to 
the deterioration of the muscular substance resulting from 
the fever. Dr. Abercrombie, in the paper already alluded to, 
states it as his opinion that the majority of cases own an 
embolic origin. It must be added that cerebral abscess, 
besides originating, as already mentioned, is a recognized 
sequel of pleuritic effusion, and of chronic disease of the 
lung, associated with dilated bronchial tubes — a sequel due, 
it must be supposed, to the formation of thrombi in the 
pulmonary veins, to their detachment, and thus to embol- 
ism of the brain. 

Symptoms. — In the author's cases the paralysis was right- 
sided in fifteen, left-sided in seven. He has never noticed 



HEMIPLEGIA. 513 

any association with aphasia, although such a condition is 
described by Gerhardt. Once or twice the child had spoken 
less well since the attack. If it be the fact that in most 
cases of right-sided paralysis aphasia is not present, it is a 
point of great interest — though it is what might be expected 
— that in early life the word-memory on both sides receives 
some cultivation, and it is only in later life that the left side 
becomes predominant. Of the right- sided cases, all were 
under six. In one or two of the cases some rigidity was 
associated with the hemiplegia, and this is not an uncommon 
occurrence; it is mentioned by Gerhardt and other writers. 
In some cases the face is temporarily paralyzed, as in adults : 
in six this was so ; in three questionably so ; in eight not ; 
in one there was ptosis also, the child dying with a yellow 
tubercle in its brain; once there was paralysis of the 
tongue. 

Prognosis. — Many of these cases are not complete, and 
either slowly recover or result in some curious anomalies 
of muscular movement, which may, perhaps, be grouped 
together under one term, athetosis, or post-hemiplegic 
chorea. 

But in some cases the loss of power is complete and perma- 
nent ; late rigidity and wasting of the affected extremities 
occur, as in adults ; and the development of the entire half 
of the body may be more or less arrested. A good many 
of these children, when they come under notice, are imbe- 
cile, and herein would appear to be an important risk of 
hemiplegia in early life. 

Treatment. — As in other forms of paralysis, when there is 
no reason to suppose that life is in danger from tubercle or 
other causes, every attempt must be made to keep up the 
nutrition of the muscles by massage, bathing, warm cloth- 
ing, etc. Electricity should also be regularly applied to the 
muscles when possible. 



514 DISEASES OF CHILDREN. 

In the earlier cases, for many there is not much to be 
done, save to keep the child quiet, and see that it is fed 
properly and kept clean. Supposing that there is any rea- 
son for suspecting a syphilitic influence, this must of course 
be treated. The ear should also be examined, in case some 
disease may have originated there and an abscess be exist- 
ing inside the skull which might possibly be reached by a 
trephining operation. 

9. Pseudo-hypertrophic Paralysis is a disease which 
attacks children almost exclusively, and appears to run 
in families, affecting several members of the same stock. 
Those affected are nearly all boys (190 out of 220, Gowers), 
and as with haemophilia, it descends to the males by the 
females. Many of them stammer and are of feeble intellect, 
and Chwostek has described an enlargement of the tongue 
in some cases. The essential features are enormous buttocks 
and calves, associated with great muscular feebleness, so 
that the gait is peculiar. The other muscles of the body 
are usually feeble, or even wasted, but they seldom show 
enlargement comparable to that of the calf and buttock. 
The disease is of such slow progress that few seem to have 
been able to watch its onset, and, lasting as it does for 
years, not many cases of death are recorded. It appears, 
however, to lead slowly to a fatal issue, either by general 
muscular atrophy and difficulty of respiration, or general 
marasmus. 

Morbid Anatomy. — In all cases where an examination has 
been made, the affected muscles have been found to be — if 
in an early stage — separated by abnormal growths of fat in 
the interstitial tissues ; if the stage be late they are replaced, 
or rather crowded out, by fat. The evidence as regards the 
state of the spinal cord is contradictory. The examinations 
of the cord in such cases have not been many, and it has 
once or twice been found diseased ; but the general opinion 



PSEUDO-HYPERTROPHIC PARALYSIS. 5 I 5 

at present held seems to be that the affection is a local one 
of muscular origin. 

The distinctive features of the disease are the slow pro- 
gress and the very gradual loss of electrical power — a loss 
corresponding to but following the wasting ; differing thus 
from that of infantile paralysis, or anterior polio-myelitis, 
which precedes and is out of proportion to the wasting. 
But a time may come in this disease when the muscles 
being in a state of complete atrophy, it is impossible to 
recognize its characteristics, and in which it is difficult to 
distinguish between it and progressive muscular atrophy. 
This is an important point in the disease. The elephantine 
buttocks and calves and the feeble intellect form a clinical 
picture which perhaps no one could well mistake ; but 
when we say that the pseudo-hypertrophy may be little, the 
muscular atrophy very general, and that in any case of mus- 
cular atrophy a growth of fat may appear and replace the 
muscles, the distinction is by no means always easy. Dr. 
Goodhart writes: " My own experience has been singularly 
meagre in typical cases, but it has supplied me with several 
of the more doubtful kind, and, inasmuch as they certainly 
form an instructive group, short notes of them are appended." 

Ernest M., aet. 12. His father is a very drowsy man, and 
suffers from intense headache. His mother has had rheu- 
matism twice, and three years ago some nervous affection, 
for which she consulted Dr. Wilkes. One of her children 
died of " water on the brain," and another of " cleft palate." 

This boy, when he first began to walk, at fifteen months, 
was noticed to do so in a strange way, walking from his 
hips, swaying from side to side, and not bending his knees. 
When four or five he improved slightly, and could walk for 
short distances without the aid of sticks. This continued 
till he was about nine, he being able to walk and play in a 
manner, but never like, or with, other boys. At nine years 



5 l6 DISEASES OF CHILDREN. 

old his powers of locomotion again deteriorated ; he refused 
to go out, and when walking would help himself by means 
of chairs, etc. For the last twelve months he has been car- 
ried about. It was also noticed that while he was becoming 
thin and emaciated, his calves and gluteal regions were well 
developed, in walking about he protruded his buttocks and 
his back was arched. His parents think that for four or five 
years his arms have become thin and wasted. His mental 
condition has always been good. He is a pale boy, with 
stammering speech, but sharp and intelligent. He lies in 
bed, and experiences the greatest difficulty in turning over. 
After much effort, he can manage to raise himself on his 
knees ; but he has to support himself with his arms. His 
legs are spare, and there is talipes equinus of both feet. 
His calf muscles are not large, but they are remarkably 
hard ; and when he lies in bed there is an unusual gap 
between the thighs, which makes it appear that there must 
be something wrong in the setting of his hips; but this is 
probably due to wasting of his adductor muscles. 

His lower limbs are capable of every variety of movement, 
but in a very feeble way. He takes his hands to help his 
legs when he wishes to cross one over the other. Tendon 
reflexes are all absent. Skin reflexes are all present. When 
he is placed on his feet his buttocks protrude and his spine 
becomes much arched, but probably only because in this 
way alone can he compensate for the talipes, and put his 
feet flat to the ground. 

With electricity, all the muscles, legs, and arms, and 
trunk, fail to respond to a weak Faradic current, to a strong 
one the left arm and leg act more than the right, and the 
trunk muscles act rather better. To a galvanic current 
applied to the muscles there is some response to fifteen cells. 
Electrical sensation is much diminished below the knees. 
Ordinary sensation is undiminished. 



PSEUDOHYPERTROPHIC PARALYSIS. 5 I / 

This case was seen by several physicians and surgeons, 
and various views were entertained of its nature, but the 
author ultimately came round to the opinion originally 
entertained by Dr. Moxon, that the case was one of the 
atrophic forms of pseudo-hypertrophic paralysis. 

Case 2. — A boy of nine, whom Dr. Goodhart only saw 
once as an out-patient. He had not been known to be ill, 
but when he ought to have walked it was found that he 
could not do so. He did not walk till he was six years 
old, and then but badly. He was better than he had been. 

He walked in a most decrepit manner, with his knees 
bent and his feet dragging. There was no incoordination 
or jerking. When lying down the limbs were still flexed at 
the knees, and the muscles of the hams were spasmodically 
taut. The limbs were spare without decided wasting, and 
without disease of the joints. He had been treated with 
electricity and cod-liver oil without decided benefit. 

This case seemed in some respects very like that already 
detailed, though its nature must be considered very doubtful. 

Case 3. — A boy of three and a half years. Had good 
health until five months before his admission. He was then 
languid and ill, and if he attempted to walk would fall down. 
He retched in the morning for a week or two. When seen 
by Dr. Willcocks, five or six weeks after this onset, he could 
walk in a tottering manner, with his legs much apart, but if 
laid on his back he could not get up again. About this 
time internal strabismus appeared. Now he can roll over, 
but cannot walk at all. The superficial reflexes are normal ; 
the deep are absent, save slight clonus at the right ankle. 
His limbs are plump, and there is moderate hypertrophy of 
the calf and gluteal muscles. The lumbar muscles stand 
out considerably when he sits up in bed, which he can do 
with a forward lean. He is unable to stand alone, falling 
forward if unsupported. In walking with support he throws 
44 



5 l8 DISEASES OF CHILDREN. 

his legs hopelessly about, and keeps them wide apart. In 
attempting to raise himself from the ground he rolls over, 
and rests his arms on his knees, but without effect so far as 
getting up is concerned. There is no lordosis. The elec- 
trical reactions are normal with both currents. 

Case 4. — A boy of nine. Began to walk at the age of 
twenty months, but he had always been weak and never able 
to get about like other children. He had gradually im- 
proved without any treatment, and was stated to walk much 
better than he could two years ago. He could walk about 
the ward quite well, but, like Case 5, he had great difficulty 
in mounting the stairs. He could only accomplish this by 
hanging on to the balustrades, and pulling himself up with 
his hands. Further, he could not rise from a sitting pos- 
ture. He would get on his hands and knees and blunder 
about, and, when he would seem almost to have accom- 
plished his purpose, would roll over again. He was a spare 
boy, of average intelligence, and without anything that could 
be called hypertrophy of the muscles, but to very careful 
examination the muscles of his thigh, and particularly the 
extensor cruris, had a hardened feeling which was suspi- 
cious. His thigh muscles failed to act to Faradism in any 
way, but they acted to twenty-four cells of a constant cur- 
rent. There was no patellar reflex on either side. He was 
galvanized and shampooed with much regularity for four and 
a half months, but very little improvement resulted. 

Case 5 was a boy of six or seven years, much like the 
last-mentioned case, who was brought to me because he 
could not walk up stairs, or pick himself up from a sitting 
posture. If sitting on the floor, he would turn over on to 
his hands and knees, but the weakness of his glutei and the 
extensors of his legs and thighs was such that he could not 
get himself into the erect posture without assistance. When 
he was erect he had no trouble in walking or running about, 



PROGRESSIVE MUSCULAR ATROPHY. 519 

though he was apt to tumble occasionally. He was a very 
spare boy, but the muscles were not definitely wasted, and 
his case is believed to be one of this group. 

The disorders of movement of patients affected with pseudo- 
hypertrophic paralysis are chiefly dependent upon weakness 
of the muscles of the lower extremities. Feebleness of gait 
is first noticed, and frequent falling ; the legs are kept wide 
apart for the sake of steadying the badly-balanced trunk; as 
they walk there is a half- rotatory, half-shuffling, movement 
to enable the forward step to be taken. Next there is the 
difficulty of getting up from a recumbent posture, the move- 
ment being accomplished by the hands, which, placed upon 
the knees and thighs, push the trunk upwards to supply the 
action of the paralyzed extensors. As the result of the 
paralysis of the extensors of the pelvis on the thighs lordosis 
follows, and later there is talipes equinus, and the patient 
cannot get his heels to the ground. The calf muscles are 
usually the first affected, then follow the glutei, and ulti- 
mately other muscles of the thigh, pelvis, trunk, and upper 
extremities. The pseudo-hypertrophy is a very variable 
element, but in most cases a great deal of quiet atrophy may 
be going on in various parts, obscured by the seeming attrac- 
tion of the parts which are enlarged. 

Diagnosis. — It needs chiefly to be distinguished from 
infantile paralysis and progressive muscular atrophy. As a 
general rule the history will allow of its distinction from 
infantile paralysis, which comes on suddenly. The latter is 
rare. 

Prognosis. — It does not appear to have any tendency to 
ameliorate. Its course is very chronic, and may last from 
childhood to puberty. Death usually comes at last from 
exhaustion. 

10. Progressive Muscular Atrophy is not a common 
disease of childhood, but it occurs occasionally, and presents, 



520 DISEASES OF CHILDREN. 

according to Duchenne, certain features which distinguish 
it then from that of adults. " This form of disease," writes 
Dr. Duchenne, " of which I have collected more than twenty 
cases, has this peculiarity, which I have never met with in 
the disease as it affects the adult, viz., that it begins in 
certain muscles of the face, giving to it a peculiar expression, 
before attacking the limbs or trunk." The following notes 
are from a case of this kind : — 

A boy of nine came for wasting of his right hand. It 
began three years before he came, and went on progress- 
ively for two and a half years, but had been stationary for 
six months. The hand ached much at first when he at- 
tempted to write ; and latterly he had had pain and weak- 
ness in the outer side of the arm. He had never had any fit. 
He appeared healthy ; but there was extreme wasting of 
the muscles of the right hand and of the forearm. The fore- 
arm near the elbow measured y^ inch less than its fellow. 

There are many other curious forms of paralysis met with 
in childhood. The author cannot say that they are common, 
but they are met with occasionally. In looking over his 
notes, and attempting to arrange the cases in some order, 
it seemed to him that they would be most instructive if they 
were simply enumerated with such notes of the cases as 
might seem desirable. 

A large group of cases, for example, may fall under the 
denomination of ataxia, using that term in a wide sense to 
indicate imperfect muscular control. In some cases it takes 
the form of rhythmical or irregular movement of the head. 
In infants this is often associated with nystagmus, and then 
is denominated the nodding spasm. Very little is known 
about this affection. There is no suspicion of blindness with 
nystagmus in this association ; and we can only say that it 
appears to be some anomalous play of nerve force ; that it 
is a disorder of dentition more particularly ; and as such is 



PROGRESSIVE MUSCULAR ATROPHY. 52 1 

liable to come and go with the occasion. Sometimes, how- 
ever, the movements are by no means regular, but are 
replaced by a decided jerking action, much more at some 
times than others. It is not only confined to infants ; the 
author has seen on two or three occasions, in older children, 
a peculiar jactitating movement of the body, trunk, and 
extremities, which has closely simulated the movements of 
insular sclerosis in the adult. Cases of this kind, perhaps, 
have passed for such in the few recorded cases of insular 
sclerosis in childhood ; but no autopsy has as yet confirmed 
the diagnosis. Closely allied to these cases come such as 
have been described as congenital chorea, and which now 
go by the name of Friedreich's disease. It is probably not 
actually congenital, but may supervene at any age after an 
acute illness. Dr. Ormerod has described two series of cases 
occurring in two families, three in one, two in the other. 
The affection seems to be hereditary, and to occur in families 
in which the progenitors showed nervous disease of one 
kind or another. It diners from ataxia in the adult in show- 
ing no pupil symptoms and no disturbance of sensation ; and 
the anatomical changes in the few cases that have come to 
an examination (six in all, according to Ormerod) have been 
diffuse gray changes in the spinal cord, occupying various 
tracts, although in most of them the sclerosis of the pos- 
terior columns has been profound. Tendon reflex has been 
absent. Dr. Goodhart gives the notes of a few such cases. 
In one case (aet. 9) the disease was said to have existed 
from birth. In another case it was apparently hereditary, 
for the father was so unsteady in his fingers that he could 
never button his shirt collar ; while his son, a boy of six, 
wrote his name in a series of unintelligible zigzags, and in 
attempting to steady himself to put a glass of water to his 
mouth, the muscular movements became violent. This 
affection had been noticed ever since he first began to play 



522 DISEASES OF CHILDREN. 

with bricks, but he had never had any fits or any illness. 
He was a sharp, nervous child, and easily frightened by 
sudden noises, and then lost his self-control and stammered. 
In another case the boy was 13^ years old. Both his 
parents were alive, but his father was described as consump- 
tive and his mother delicate. There was epilepsy in the 
family. He said that as long as he could remember — and 
a relative who brought him said since babyhood — he had 
always been feeble and tottering in his walk, his head appa- 
rently too heavy for his body. He had always had a diffi- 
culty in dressing himself, and he would be often untidy and 
dirty. His feebleness and irregularity of movements had 
increased of late. He was a spare boy, but his muscles — 
what there was of them — were well developed. He spoke 
in a slow, jerking, staccato way, quite like that of insular 
sclerosis, and his whole manner gave a like impression. 
His intellect was clear. His head was constantly nodding, 
like a case of paralysis agitans, but more forcibly than is 
usual in such a case, and when he walked, he staggered 
about like some cases of tumor of cerebellum or pons. 
There was, however, an absence of the excessive irregu- 
larity of the muscles under the influence of volition, such 
as characterizes insular sclerosis. He had fair power in 
both his arms, although the grasp was feeble for a boy of 
his age, and the left side worse than the right. He could 
pick up small objects at times perfectly well ; at others, 
only with some tremor and uncertainty ; and, as a rule, in 
drinking, he put his head to the cup, his hands being too 
unsteady for the purpose. He would lie and sit quite quiet. 
Movement was accompanied by the rhythmical head move- 
ment. He had good power in his legs and could lift them 
without tremor. He walked with his legs wide apart, and 
their movements were jerky and incoordinate, his heels 
coming to the ground like a case of locomotor ataxy. He 



PROGRESSIVE MUSCULAR ATROPHY. 523 

was unable to stand with his feet together and his eyes 
shut. 

The abdominal reflexes were well marked, the cremasteric 
feeble. The patellar tendon reflexes absent. He said, on 
being questioned, that he often had darting pains in the 
calves of his legs and pins and needles in his hands and feet. 

His sight was very imperfect ; he could only read Snellen's 
18 at four feet, 0.5 at four inches. His pupils were sluggish ; 
the optic discs white, a condition Dr. Brailey considered to 
be one of slight atrophy. He had no trouble either in 
urination or defecation. 

He was under observation for a month, the treatment 
adopted being faradization of the spine three times a week. 
He seemed decidedly steadier under this treatment. 

A third case, a child of six, had a fit, and was idiotic, 
though sensible enough to express his satisfaction that he 
had " done with the doctor " after we had finished exam- 
ining him. He used his hands in an ataxic way ; got at a 
button of his waistcoat with difficulty, and only after many 
efforts, in which the arms made wide excursions, did he suc- 
ceed in unbuttoning. The child spoke slowly and labori- 
ously, and walked in a tottering way, and would fall quickly 
if not held up. 

All these were boys. In a girl of four the disease came 
on after "brain fever," probably the initial fever of measles 
and pertussis which she had at that time. 

Dr. Goodhart has lately recorded, at the Clinical Society 
of London, a series of five cases in one family, which may 
well be included in this group, although the clinical symp- 
toms were more those of insular sclerosis. The ages of the 
children were 8, 6^, 5, 3 years, and 14 months. The eldest 
was the most severely affected, the youngest having only 
nystagmus. In these cases the knee jerk was exaggerated. 

It is very difficult indeed to refer these cases to any actual 



524 DISEASES OF CHILDREN. 

lesion ; and some would get over the difficulty by calling 
them congenital chorea. So far as treatment is concerned, 
it is useful to consider them — like the cases of some of the 
imbeciles with spastic paralysis — as instances of faulty con- 
trol and training, which will be bettered by a laborious and 
patient practice. The same thing happens under other cir- 
cumstances. After diphtheria, for example, and in many a 
case of tumor of the pons, the movements are very similar, 
and here there appear to be exactly the conditions required 
for the necessities of the hypothesis that cortical control 
being stopped, or rather impeded, tremor and jactitation 
result. 

This, indeed, is often the question for diagnosis. A child, 
with tottering gait and jactitating arms, comes for treatment. 
The first thing that occurs to one is the possible existence 
of tumor of the pons or cerebellum. As a mere question of 
muscular disorder, such a case might readily pass for one 
of tumor. The decision must rest upon the existence or 
not of other evidences of tumor, such as optic neuritis, 
headache, vomiting, and the like. 

11. Facial Paralysis, of any persistence and complete- 
ness, is, in adults, far more commonly due to peripheral 
causes, such as exposure, than to any known central lesion. 
In children, the reverse happens, and it is but seldom due 
to the like cause. Dr. Goodhart has seen it once only in a 
girl of about eight years. Henoch and Steiner have, how- 
ever, recorded cases of this kind. It occurs sometimes in 
infants soon after birth, and is due to injury in delivery. It 
usually passes off within a short time; but the affection 
sometimes remains throughout life. A congenital and irre- 
mediable form is described by Henoch, the cause of which 
is unknown. 

Abscesses and enlarged glands behind the angle of the 
jaw also produce facial paralysis ; and it has been known to 



INTERNAL STRABISMUS. 525 

result from congenital syphilis (Barlow); but, more usually, 
it connotes aural discharge and disease of the middle ear. 
Such cases are prone to die from tuberculosis. Disease of 
the ear may cause abscess of the brain and suppurative 
meningitis, as in later life ; but the author's experience 
quite coincides with that of others, that tuberculosis, in one 
part or another, is liable to supervene when aural discharge 
and facial paralysis are co-existent. There is usually exten- 
sive disease of the temporal bone in such cases, and perhaps 
it is thus that it is an evidence of the tubercular tendency. 
Facial paralysis is, therefore, often of very sinister omen 
in infants and young children. 

12. Hemiatrophia Facialis is a very rare condition, but 
some forty or fifty cases have been recorded. Latterly, two 
very striking cases, with photographs, have been published 
by Messrs. Jessop and Brown, from Gee's wards, in the 
" St. Bartholomew's Hospital Reports." The disease is not 
exclusively infantile ; but Gerhardt has collected ten or 
twelve cases in children, and Jessop states that thirty-five 
began before the age of twenty. 

It is characterized by wasting of Hie muscles of one- 
half of the face, generally the left. The palpebral fissure 
narrows, the eye sinks in, the cornea becomes ulcerated, 
and the eye destroyed. In many of the cases there is 
neuralgic pain and some early pigmentation of the skin. 

Two other spasmodic affections may be mentioned in 
one group — viz., internal strabismus, nystagmus and retrac- 
tion of the neck. 

13. Internal strabismus is the common form of squint. 
It may be either concomitant or paralytic ; the former is 
due to excessive development or excessive use of the in- 
ternal, the latter to paralysis of the external, recti. Con- 
comitant squint is much the more common and is mostly 
due to hypermetropia. Dr. Brailey states that some 



526 DISEASES OF CHILDREN. 

error in refraction is present in at least 70 per cent, of all 
cases, although in, perhaps, a third of this number the hyper- 
metropia is so low that it would be difficult to accept it as 
the real cause of the squint. But by this prevalence of 
hypermetropia sufficient to produce it, a difficulty is intro- 
duced because the squint is frequently stated to have fol- 
lowed upon a convulsion. A history of this kind must be 
received with great caution, nevertheless it is probably true 
for some cases, and one can then only suppose that the 
central disturbance has upset a muscular balance, hitherto 
only maintained with difficulty, and which, once disturbed, 
is unable to recover itself. For such cases as are not due 
to hypermetropia, some are thought to be dependent upon 
some congenital want of balance in the ocular muscles; 
others upon some defect in vision ; others, perhaps, upon 
defect in the centres for the movements of the eyeballs 
either of congenital origin or arising out of the disturbance 
of acute meningitis and so forth. Paralytic squint is most 
often a symptom of tubercular meningitis ; occasionally, 
perhaps, one of the results of a by-gone basal meningitis. 
The treatment of squint belongs to ophthalmic surgery. 

14. Nystagmus (oscillation of the eyeballs), when not a 
symptom of the nodding spasm or hydrocephalus, is usually 
associated with amaurosis, or defective sight. Of six cases, 
four were blind; it is usually met with in infants a few 
weeks or months old, and is liable to be associated with 
blindness of any form. Thus it is found with cataract, as 
well as with congenital defects at the fundus oculi. The 
nature of this muscular anomaly is obscure, but the fact 
that many cases occur when blindness has prevented the 
acquirement of the power of fixation seems to suggest that 
the faulty movement, if sometimes due to a central lesion, 
may at others be the result of the want of training which 
the ocular muscles suffer when faulty vision is congenital or 



CERVICAL OPISTHOTONOS. 527 

dates from very early infancy. The lens and the fundus 
oculi should be carefully examined for local disease. The 
presence either of cataract or possibly some local distribu- 
tion of retinitis or choroiditis might allow us to hold out 
some hopes of relief by operation ; for probably it can be 
said of this as of other muscular aberrations, that, no matter 
what the primary disease may be, some improvement may 
be expected by allowing education of the muscles to come 
into play. 

15. Cervical Opisthotonos is a symptom only, but it is 
of such importance as to demand a paragraph to itself. 
Gee and Barlow, in the St. Bartholomew's Hospital Reports, 
give notes of twenty-five cases of this affection in infants, 
varying from birth up to nineteen months. It is sometimes 
of gradual, sometimes of sudden, onset. It is often chronic, 
tends to remit in severity, is associated with rigidity of the 
limbs, convulsions, and hydrocephalus, and, in the majority 
of cases, terminates fatally. In all the cases (six) in which 
an examination was made after death, a basal meningitis of 
a non-tubercular nature was found. 

These authors note recoveries in a somewhat cautious 
manner, from the known tendency to remission which the 
disease exhibits; but there can be no doubt that retraction 
of the neck does subside in some cases, and that even a 
meningitis of the base with retraction occasionally gets well. 

The case must be gone into completely, as sometimes the 
opisthotonos has appeared to be like torticollis, either of 
rheumatic origin or due to some temporary gastric disturb- 
ance. 

All these three affections — strabismus, nystagmus, and 
cervical opisthotonos — are worthy of investigation, from the 
interest which attaches to them with respect to the observa- 
tions of recent years as regards the localization of cerebral 
functions. Ferrier has shown that retraction of the head is 



528 DISEASES OF CHILDREN. 

associated with destruction of the posterior part of the middle 
lobe of the cerebellum, and that disturbed movements of the 
eyeballs are found with other cerebellar lesions. It seems, 
therefore, not at all unlikely that what has been shown to 
be true for retraction of the head, both experimentally and 
clinically, may also be sometimes true for nystagmus and 
some forms of squint, and that a case may occasionally find 
its explanation in some bygone basal meningitis. 

16. Torticollis, or stiff neck, might perhaps be made the 
text for dwelling upon the question of the existence of 
muscular spasm from local causes. But, of late years, this 
latter group of cases has been by common consent much 
reduced by enlarging the area of central or nerve spasm. 
Wry neck, however, does seem still to remain more local 
or functional than central. Although in ignorance of its 
cause, perhaps it may be introduced here as related, the 
author thinks, to occasional cases of retracted neck. 

Torticollis is a frequent affection of childhood, and may 
be said to represent the lumbago of adults ; it occurs in 
rheumatic families, in children who are anaemic and out of 
sorts ; it may also occur as a result of reflex irritation from 
enlarged glands, decayed teeth, etc. 

It is a disease of childhood, not of infancy, and cannot, 
therefore, be easily confounded with the spasm and contrac- 
tion due to the sterno-mastoid tumor, sometimes found 
within a short time of birth, and supposed by many to be 
the result of injury to the neck in delivery. 

Treatment. — Any local cause must be looked for, and, if 
possible, remedied. If none can be found it is advisable to 
give some gentle laxative and saline, such as the effervescing 
citrate of magnesium, pyretic saline, or some such mild 
aperient, one drachm three or four times a day, and, after a 
day or two to give Easton syrup or Parrish's food, or a like 
tonic. 



SPASTIC PARALYSIS. 529 

17. Spastic Paralysis is a term which, including as it 
does many cases of hemiplegia, overlaps in some measure 
the accounts already given of the latter disease. It is, no 
doubt, best known in adults as spastic paraplegia, or spas- 
modic spinal paralysis, and its symptoms are tolerably con- 
stant. They are gradually developing motor paraplegia, 
associated with muscular twitchings and rigidity, sometimes 
contractures, and a great increase of the reflex activity of 
the tendons. . The paralysis appears to be in great measure 
due to the excessive reflex excitability and the muscular 
rigidity which exist, and which lead to the characteristic 
gait ; the rigid limbs being dragged along with difficulty 
and the toes clearing the ground badly. Certain negative 
symptoms are not less important as regards the diagnosis. 
There is no affection of sensibility, no wasting of the muscles, 
and no disturbance of the functions of the bladder. But 
spasm is by no means uncommon in the paralysis of chil- 
dren. It is said more often to take on a one-sided pattern, 
and has received the name of spastic hemiplegia ; but 
whether hemiplegic or paraplegic chiefly, certain peculiar- 
ities attach to it. First of these is the frequency with which 
it goes with idiocy and also with fits. Often cases, six boys 
and four girls, of which the author has notes, eight were 
imbecile ; two only are noted to be intelligent. It some- 
times occurs in the youngest infants with small brains 
(microcephalus) ; but more often it happens that the child 
has been quite well up to a certain time, and has suddenly 
been taken with severe brain symptoms and fits. The in- 
ability to walk has closely followed, and the idiocy has 
slowly supervened. These points are perhaps better illus- 
trated by short notes of cases : — 

Case i. — A boy of two and a half has squinted since 
birth, has never been intelligent, and never walked ; has 
never had a fit of any kind ; he is quite imbecile ; there is 



530 DISEASES OF CHILDREN. 

internal strabismus and nystagmus; the optic discs are 
bluish-white and atrophied; both legs move badly; they 
are spasmodically flexed at the knees, and can only be kept 
straight with difficulty. He is quite unable to stand, for this 
reason. 

Case 2. — A boy of seven had a fit at the age of three 
years, remained well for twelve months, and gradually after 
this lost power of walking and talking ; at first he walked 
on his toes. When lying down, his legs are rigidly extended, 
with pointed toes, resisting attempts at flexion. 

Case 3. — A girl, aged four. The original notes are lost. 
She is imbecile; has fits; there is internal strabismus, and 
the fundus oculi is hazy and swollen ; her legs and arms 
become quite rigid on slight stimulation ; the legs are so 
rigid that she is quite unable to stand alone. 

Case 4. — A boy of six and three-quarters. His paternal 
aunt became idiotic after fits ; a great-aunt died in an asylum 
with brain disease ; three other children died with convul- 
sions. The present patient was suddenly taken with vomit- 
ing while in bed five weeks before. A fit followed quickly, 
in which he had deviation of head and eyes to left, and loss 
of power in the right leg. He had many fits afterwards, ex- 
tending over a fortnight, and since then has lost his memory 
and power of speech. He does not now recognize his rela- 
tions. He is idiotic, but does as he is told. The right arm 
is rigid, jerking in its movement, and tremulous when ex- 
tended. The leg is in a similar state, although he manages 
to walk in a clumsy and unsteady manner. Sensation is 
normal. He is said to have been quite blind when he had 
the fits, and quite without sensation on the right side, even 
to the pricking of a pin. The fundus oculi is normal. 
Bridge of nose rather sunken, but no evidence of congenital 
syphilis. 

Case 5. — Girl, eight and a half years. Quite well and 



SPASTIC PARALYSIS. 53 I 

intelligent a year ago. Had a bad feverish attack, and was 
in bed a fortnight. When up again, was unable to use her 
legs well, but crawled about with a chair for six months, and 
now cannot walk at all. Has been getting babyish and 
mischievous for some months ; is now more like a child of 
four in her manner. Both legs very wasted ; slight contrac- 
tion of the flexors of the knee, so that she is unable to 
straighten them or put the sole to the ground. Pupils equal 
but sluggish ; hearing good, no otorrhoea ; teeth peggy, and 
crammed into the jaw very irregularly. 

Case 6. — Boy, aged three and a half. Early history want- 
ing. He cannot talk, and if he tries to walk, all his muscles 
become stiff. His hands and arms are spasmodically con- 
tracted, the wrists being strongly flexed, and the fingers 
over-extended, so as to be bent backwards toward the dor- 
sum. Muscles flabby, but not wasted. Expression imbe- 
cile. No note of fits. 

Case 7. — Boy, four and a half. Never had any illness, 
but never able to sit or walk ; head large ; high arched 
palate ; moves his legs irregularly, with much rigidity of 
muscles when attempting to walk, and temporary talipes 
equinus when put on feet. When lying on his back the 
legs and thighs become rigidly flexed ; arms, when attempt- 
ing to grasp, are shot out in a rigid extended manner; but 
there is some control of left arm ; constant tremor of right 
arm, and athetosis of fingers. 

Case 8. — Girl, aged five. Convulsions a week after birth ; 
has never crawled or walked, and talks badly. Intelligent ; 
sight and hearing good ; picks up things clumsily — the 
ulnar side of hand and fingers being extended in a spas- 
modic manner — right side most marked ; in walking there 
is much initial rigidity of the muscles, which subsequently 
subsides. Some talipes equinus at first ; right leg more 
flabby and smaller than left ; both legs become rigid irregu- 



532 DISEASES OF CHILDREN. 

larly, apparently from irregular muscular action, partly reflex 
and partly voluntary; knee reflex absent on both sides. 

Case 9. — A girl, aged two years. Early history wanting. 
The parents are healthy ; but one other child has had " fits." 
This child has a markedly contracted narrow forehead, with 
a microcephalic appearance and manner. The fontanelle is 
closed : there are no protuberances on the skull, and no 
evidence of rickets ; the face is well developed ; the arms 
and forearms are flexed and rigid ; the thumbs inturned 
upon the palms, and the fingers clasped ; the legs also are 
rigidly flexed. Directly she is touched the whole body 
passes into a state of rigid spasm, lasting for a few seconds. 

The sight is deficient in certain directions, and there are 
large patches of choroidal atrophy with central pigmenta- 
tion. Both of the discs are white, with pigmented borders, 
and on the right side one of the atrophic patches occupies 
the place of the yellow spot. 

In a tenth case, a boy aged three years, the distribution is 
paraplegic, and there is internal strabismus, with a skull 
of microcephalic type. But the child is rather precocious, 
and no cause of any kind could be elicited. The child had 
never walked. 

The disease, as it is found in children, is more general 
than in adults, and in many cases the rigidity is to be noticed 
in all parts of the body, or, at any rate, in all four extremi- 
ties. One side may be more markedly affected than the 
other. Gowers attributes this to a cortical lesion, in many 
cases happening during delivery, which destroys the motor 
areas on one side and extends across the median line to the 
leg centre on the other side. The cause of the spasm would 
in many cases appear to be due to uncontrolled reflex 
action, for directly the child is touched or startled in any 
way, all the muscles of the body start into a tonic spasm 
for a few seconds, and gradually relax, the process being 



SPASTIC PARALYSIS. 533 

repeated over and over again, till the centre becomes 
temporarily exhausted, and the same stimulus fails to act 
so completely. 

These cases are sometimes, probably always, due to some 
central lesion. They are rightly called hemiplegic, ill the 
sense that one side is often worse than the other, and the 
evidence is in favor of some one-sided lesion of the brain. 
In this respect they are evidently of the same class as the 
post-hemiplegic disorders of later life, but these are uni- 
lateral ; in young children they tend to be bilateral. This 
difference probably finds its explanation in the time of life 
at which the lesion occurs. Now as at later dates, injury 
to the brain causes loss of control over the opposite side of 
the cord, and that half thus becomes more dominantly 
reflex than it should. The nerve-cells thus acquire a habit 
of quick discharge, and the blood supply necessarily 
becomes altered to meet the altered physiological needs. 
In the state of development such as now exists, it is impos- 
sible but that the fellow half of the cord should feel the 
influence of this uncontrolled action, and it also becomes 
timed to act in a similar way, although to a less extent. 
Thus the diseased action becomes more or less general. In 
the fully trained adult cord there would, at any rate, be less 
risk of such perverted action occurring, and, as a fact, it is 
not common. But in adults we associate this action on the 
one side with a degenerative change in the anterolateral 
tract of the cord corresponding. Whether this is present 
in children is not known, but it seems hardly likely, at any 
rate in those cases in which it is associated with a microce- 
phalic brain. Perhaps it is, as Erb suggests, that the normal 
strands in these cases are never properly developed. It 
does not appear to me, however, that any hypothesis of this 
kind is necessary ; we have already a sufficient explanation 
in the damaged condition of the cerebral cortex, with its 
45 



534 DISEASES OF CHILDREN. 

consequent deficiency of intelligence and control ; given 
this, and the functional development of the cord becomes 
arrested at the primitive stage of reflex action. The muscles 
are in consequence improperly controlled, irregularly exer- 
cised ; there is no harmony between the groups of muscles 
for complex action, they lapse into a state of spasm or con- 
tracture, and we have the very conditions with which we 
are concerned. Moreover there is one important fact about 
these cases which seems to point in this direction — viz., that 
some of them improve very much as they grow in years. 
Case i is now ten and a half years of age. He is much 
more intelligent, has learned his letters, and can walk about 
very fairly, though he is clumsy with his feet. Dr. Good- 
hart has watched an almost exact counterpart in another 
boy from infancy, till now when he is nine years old, and he 
adds that the other symptoms are somewhat variable in 
these cases — in some there is muscular atrophy, in others 
none ; in one or two the muscles have seemed to be 
replaced by fat, as in the pseudo-hypertrophic paralysis; 
and in some the eyes may be affected with cataract, retinitis 
pigmentosa, or choroiditis with atrophy. 

Prognosis. — This cannot be very hopeful ; nevertheless, 
with much patience and attention, children may and do 
improve considerably. There is not, however, much chance 
of their being other than imbecile, and, even if at first the 
disease is not associated with epilepsy, there is a strong 
probability of this condition developing as puberty ap- 
proaches. 

Treatment. — But little can be done medicinally. If there 
is any definite lesion, iodide of potassium or iodide of iron 
might possibly prove useful, and bromide of potassium and 
sodium, or one of these combined with the iodide, may be 
given to control the fits. All possible practice should be 
given to walking, and to as many definite muscular move- 



INFANTILE CONVULSIONS. 535 

ments as possible. Regular daily shampooing is also of 
service. Electricity has not seemed to me to be of much 
benefit. 

18. Infantile Convulsions include, besides severe and 
general convulsions, many cases of local convulsive spasm 
or rigidity, such as strabismus, laryngismus, and that rigid 
inturning of the thumbs upon the palms and rigid flexion 
of the feet which have received the name of tetany, or 
carpo-pedal contractions. There is no essential distinction 
between infantile convulsions and epilepsy, so far as the fit 
is concerned ; the difference lies in the temporary character 
of the one and the chronicity or tendency to recurrence of 
the other. Nor will it do to push this difference too closely, 
for infantile convulsions may last, if not treated, for months. 
The author finds a tendency to class all convulsions under 
two years of age as " infantile," and all over that age as epi- 
lepsy, but in the epileptic cases are several in which the 
fits have continued since infancy. Perhaps this fact may 
have its instruction for us. The chronic tendency to con- 
vulsions which we call epilepsy unquestionably has much 
of habit in it ; each additional fit that comes makes the brain 
more prone to another, and it may well be that the convul- 
sions of dentition, unchecked at their first onset, may in 
some cases become a confirmed habit, and thus chronic or 
epileptic. Eight out of twenty-six cases of epilepsy had 
suffered from infantile convulsions at an earlier date, and 
Gowers, working with much larger numbers, still makes 
the proportion as high as seven per cent, of all cases investi- 
gated, and he adds, it seems reasonable to ascribe to these 
convulsions of infancy a share in predisposing to the convul- 
sions of later life. Neurotic heredity, according to the same 
observer, is found in thirty-four per cent., the same as for the 
whole of life. 

The convulsions of dentition, no doubt in part influenced 



536 DISEASES OF CHILDREN. 

by hereditary tendencies, are yet, it is now generally ad- 
mitted — following the observations of Jenner, and later of 
Gee — largely associated with rickets ; and it is believed that 
the impaired nutrition of which rickets is the expression is 
productive of an irritable or unstable condition of brain, 
causing it to discharge itself spontaneously, or on what 
would otherwise be an inadequate stimulus. A certain pro- 
portion of cases is due to actual brain disease. Of 102 cases 
recorded by Dr. Gee, one-fourth were due to local disease, 
and the remainder to general causes. These include various 
conditions, but only one of any numerical consequence apart 
from rickets — viz., some acute exanthem. Reducing the 
number from these causes, fifty-six cases remain, and every 
one of them was rickety. 

Convulsion, then, during dentition, if it be not due to the 
onset of an acute febrile disturbance — and even in such case 
it is still possible that the same condition may sometimes 
be at work — is one of the modes of expression of rachitic 
malnutrition, and this is really the important factor in the 
causation of the disease. It is quite unnecessary to take 
up space by enumerating all the secondary conditions which 
in this state will induce a fit. It may be said, with Gee, 
that the convulsive diathesis affords an opportunity to a 
thousand irritants, natural and unnatural. The reader can 
readily fill in for himself some of these numerous local fac- 
tors — the dentition, the worms, the indigestible food, the 
excited play, the febrile state, and so on. 

Symptoms. — These are not quite the same in infants as 
in older children and adults. Infants are said to turn pale, 
to turn up their eyes, to get black in the face, to catch their 
breath, to become livid about the lips. Sometimes even 
babies will scream violently or give a cry before becoming 
convulsed. Sometimes they lose consciousness only, and 
wake up with a start. Once the author noted insensibility, 



INFANTILE CONVULSIONS. 537 

with a clonic convulsion of head and upper part of chest ; 
the chin on the sternum, and inspiration snoring. Laryn- 
gismus is common : sometimes there is tremor in sleep ; 
sometimes the whole body becomes stiff, and the breathing 
impeded, in a half-tetanic state ; sometimes even in infants 
the character of the adult fit is maintained ; there is the 
initial pallor, followed by lividity and convulsions — the fit 
commencing with a cry, and succeeded by somnolence. 
Lastly, may be mentioned twitching of the lips, half-closed 
and winking eyes, startings, and the condition of carpo-pedal 
contraction — the tetanic of Trousseau. In this condition the 
thumbs are bent rigidly across the palms of the hands, the 
sole of the foot is arched and the toes flexed. This state 
may last for many days, and remit and recur. Its import- 
ance is as an indication of the convulsive diathesis. It is a 
disease which occurs at all ages, but is far more frequent in 
infancy — according to Gowers, in the second decade of life 
also — than at any other period. In infancy it is more 
common in males than in females, and, as with convulsions, 
it keeps close company with rickets. 

Diagnosis. — The first point must be to search carefully 
for indications of rachitis ; their presence will tend to make 
one examine more critically the evidences of local disease 
which may present themselves. It will also be necessary, 
as far as possible, to assure ourselves of the absence of any 
acute exanthem. Very likely this will be impossible, for, in 
infants, pyrexia is quickly induced from numberless causes; 
and the local factor which produces the convulsion will be 
liable to provoke febrile disturbance also. If an exanthem 
can be excluded, then there are the various local factors to 
be sought, chief of importance being brain disease, such as 
meningitis from disease of the ear, hydrocephalus, and so 
on. Excluding these, as we probably may do, in the absence 
of any evidence of cerebral disease save the convulsions — 



53$ DISEASES OF CHILDREN. 

and, perhaps, a bulging fontanelle, to which allusion has 
already been made, as having but little significance neces- 
sarily attaching to it — we next examine into the question of 
teething, food, state of bowels, etc.; and we shall by that 
time probably be in a position to form some idea of the 
cause of the convulsion in the case before us. 

Results. — Hemiplegia may follow an attack of convulsion. 
It may be only of temporary duration; but should it not 
pass off, or should any rigidity come on, some local disease 
of the brain in all probability exists. Children sometimes 
stammer and are stupid after a fit. In several cases of idiocy 
the history of a fit is the first note of evil. Strabismus 
appears to be one of the common results of convulsion, the 
preexistence of hypermetropia notwithstanding. 

Lastly, may be noted the curious and interesting observa- 
tion of Mr. Hutchinson, that zonular cataract is a frequent 
associate of infantile convulsions and rickets. It may be 
congenital, therefore the accuracy of calling it a result may 
be questioned ; but it may also form after birth, and it 
usually affects both eyes. 

Prognosis. — Many children die from convulsions at this 
early period of life ; and frequent and violent convulsions 
must necessarily constitute a serious danger. This will be 
the more especially the case when dependent upon such 
conditions as the onset of scarlatina or measles, or the 
existence of whooping-cough. In the case of local disease 
of the brain, including, as it does, meningitis of all kinds, 
tubercle, tumors, chronic hydrocephalus, etc., the disease 
can hardly be increased in gravity by the onset of convul- 
sions. But where it is associated with rickets, and the 
initial convulsions do not cause death, there is every hope 
that treatment will be successful in warding off their repe- 
tition. 

Treatment. — In the actual convulsion what can be done 



EPILEPSY. 539 

should be done to stop it. This is not much ; but it is 
probable that the old-fashioned treatment, often called de- 
rivative, is of use, by lessening the turgid state of the brain 
which the fit produced, but which probably tends to prevent 
the restoration of equilibrium. To this end a hot mus- 
tard bath is advisable, and an aperient should be given at 
once. Calomel is easy to administer, and is effective, and 
a couple of grains may be given to a child of a year old. 
All this done, an ice-bag should be kept in contact with the 
head. When the child comes round, five grains of bromide 
of potassium may be given immediately, in some syrup; or 
if there be much somnolence after the fit, ten grains in 
solution may be given by enema. If this be unsuccessful, 
bromide of sodium may be substituted, or chloral combined 
with the bromide. As already remarked, young children 
take both bromide and chloral well. Five grains of each 
may be given in combination to a child a few months old. 
The editor prefers smaller doses of chloral and larger doses 
of the bromide, for example, two grains of chloral and ten 
grains of bromide of potassium for a child of one year. If 
the convulsions be due to blood-poisoning of any kind, it is 
better to wait after the convulsions have subsided to see 
what course the case threatens to take. It need not neces- 
sarily be of greater severity because it has commenced by 
convulsions. Should it threaten to be so, quinine should 
be given at once. 

19. Epilepsy. — From the tables published by Gowers 
some very important facts are learned concerning the disease 
as met with in children. Out of 1450 cases, \2 x / 2 per cent, 
commenced during the first three years of life ; 5 y 2 per cent, 
of the whole occurred in the first year; from then to five years 
the numbers fall, till at five the minimum for the early period 
of life occurs, only 1.7 per cent, beginning at that time. At 
seven, the commencement of the second dentition, the num- 



540 DISEASES OF CHILDREN. 

bers rise again, then fall, and rise again, until at fifteen or 
sixteen the maximum for this period of life is attained with 
5^ per cent, of the total numbers. Of those cases which 
occurred in the first three years of life, ascarides, sunstroke, 
falls, injuries at birth, are given as causes in a few cases; 
but the far larger proportion occurred during the first den- 
tition, and were attributed to teething ; and the total num- 
ber of cases so caused may be put at 7 per cent, of the whole. 
If we further allow, as we can hardly escape doing, that 
rickets plays a large part in the occurrence of convulsions, 
and add other cases to those given in which rickets was 
probably present in early life, although the epileptic recur- 
rence did not occur till later, we have rickets playing the part 
of a predisposing cause in 10 per cent, of the whole num- 
ber. The neurotic heredity was in great measure transmit- 
ted from actual epilepsy (three-fourths of the inherited 
cases) ; but insanity was combined with it in a considerable 
number of cases. Of other diseases, chorea existed in other 
members of the family in numbers not far short of those of 
cases of insanity. 

Epilepsy is sometimes associated with malformation of 
the brain; sometimes it comes on after hemiplegia, or blows, 
or a fall upon the head. 

Symptoms. — The chief feature of epilepsy is loss of con- 
sciousness, and this takes place in very varying degrees- 
Children will sometimes have a violent convulsion with bit- 
ten tongue, and insensibility, succeeded by stupor, as is so 
commonly seen in adults ; but a large number only faint or 
lose consciousness for an instant,* and no more, but with a 
recurrence many times in the twenty-four hours. There is 
a sudden pallor, perhaps a momentary drop of the head, 
while anything in the hand falls as from one momentarily 

* Petit mal.— Ed. 



EPILEPSY. 541 

overcome by sleep. The fits in children have a special ten- 
dency to occur by night. The nocturnal fits may consist of 
mere tremors, or the child may appear to be awake but with 
fixed gaze. It is perhaps convulsed, or laughs and talks in 
an idiotic manner. Observations as regards an aura are 
perhaps hardly reliable ; but one may elicit descriptions of 
giddiness and of disturbed sensations in the arm or in the 
fingers, and once in a girl of nine Dr. Goodhart elicited the 
statement that the fit regularly began by a complaint of 
abdominal pain. 

Diagnosis. — The paragraph relating to the diagnosis of 
infantile convulsions may be referred to. 

Prognosis. — This is neither better nor worse than it is in 
adults. A great many children improve under proper treat- 
ment, and the frequent recurrence of the fits is kept in abey- 
ance. When the fits are of recent origin, or have occurred 
but seldom, there is always a hope, to be encouraged in 
every possible way, that they may never recur ; but, as in 
adults, there are also some very obstinate cases which resist 
all treatment. Some of the worst cases are associated with 
confirmed hemiplegia, late rigidity, and so forth. If the fits 
are very frequent and intractable, there is a fear of imbecility 
following after. 

* Treatment consists of attention to the child's hygienic 
condition, to see that his food is of proper quality, that his 
bowel's are regular, sleep good, etc. For the arrest of 
the convulsions bromide of potassium is the most generally 
useful remedy. It may be given without risk (save with one 
exception) to the youngest children. At a year old we may 
begin at five grains three times a day, and even increase the 
dose if necessary. For older children, of ten and twelve, 
ten, fifteen, and twenty grains may be given three times a 
day. If this should not be successful, very likely the bro- 
mide of sodium will be so. Dr. Goodhart thinks that the 

46 



542 DISEASES OF CHILDREN. 

latter is more useful with children than the former. Some- 
times the iodide combined with the bromide is useful. 
Bromide and digitalis, or bromide and belladonna, are good 
combinations when a neurotic heart is associated with the 
fits. Oxide of zinc is a good remedy for children, in three- 
or five-grain doses, and borax is recommended by Gowers. 

A child that has had epilepsy will require careful watch- 
ing at particular periods. The figures already quoted from 
Gowers show that both the second dentition and also 
puberty are times at which the disease is likely to show 
itself. Therefore the bromide should be resorted to if any 
threatenings occur. Mental study should never be allowed 
to proceed to the extent of exhaustion. Exercise should be 
abundant, and food nutritious ; while all things that make 
for a too continuous or excessive, and therefore morbid, 
nervous erethism, must be avoided or controlled. 

The one risk attaching to the administration of the bro- 
mide is its liability to produce lumps, or indurated, soft, 
granuloma-like swellings over the body. The risk of this 
may be considerably lessened by combining some liq. arseni- 
calis, or liq. sod. arseniatis with it — this drug is very readily 
borne by children ; the bromide should never be continued 
for long periods continuously. 

19. Nightmare, or Night Terror, is a nervous affection 
of young children, and is allied to the much rarer phenomena 
of sleep-walking. It is also akin, the author thinks, to one 
form of nocturnal incontinence. All these conditions may 
be described as sleep disorders where cerebral undercur- 
rents seethe below a placid surface. Nightmare is usually 
supposed to have much to do with dyspepsia, and in 
mucous disease, although as a rule the nervous irrita- 
bility is lessened, night terror is a very common feature ; 
in chronic indigestion, too, nightmare and dreamy sleep, 
modifications of the same symptom, are constant. The 



FUNCTIONAL NERVOUS DISORDERS. 543 

editor has also seen them rapidly disappear under a treat- 
ment directed to the removal of the catarrhal condition 
of the gastro-intestinal canal. Henoch, however, will not 
allow that food has anything to do with it, and Dr. Good- 
hart agrees with him for the most part. The children in 
whom it occurs are usually quick, excitable and nervous, 
and it runs in rheumatic and choreic families. It would 
be interesting to follow it up in relation to epilepsy and 
other nervous disorders. Of thirty-seven cases seen by the 
author, there were twenty-one boys and sixteen girls, and 
nineteen of these had a family history of rheumatism ; some 
others came of a nervous or neuralgic stock. 

It is to be treated with bromide of potassium, or that 
and chloral, and in this way always subsides. It is a 
malady of little detriment in itself; but, as an indication of 
a nervous organization, it is most valuable. It is the 
" slacken speed " to the engine-driver which must never 
pass unheeded. If properly treated, one of the graver ner- 
vous disorders so common in later life may be prevented. 

20. Functional Nervous Disorders. — Of other func- 
tional nerve disturbances in any marked form, such as are 
met with in adult life, childhood is not prodigal of examples. 
The author, however, has seen functional vomiting and an 
extreme case of functional hiccough, each in girls about 
twelve years; and moderate hystero-epilepsy in girls often 
and twelve. In another girl of twelve there was functional 
paralysis of the abductors of the vocal cords. She had a 
fit in the out-patient room, and became insensible and rigid, 
but was not convulsed. She had also a croupy cough; but 
on examining the larynx, which she very readily allowed, 
there was an entire absence of any morbid appearance, 
except in the position of the vocal cords. These played 
about somewhat close together during expiration, and during 
inspiration the anterior parts completely closed, the left over- 



544 DISEASES OF CHILDREN. 

lapping the right, and leaving only a chink posteriorly for 
the entrance of air to the lungs. The paretic state of the 
abductors was clear, and the functional character of the 
malady was equally so, for it quickly improved, so that in 
the course of half an hour it had almost disappeared. This 
patient had been in the hospital under Dr. Taylor for cata- 
leptic attacks, and, in one of her fits, her eyes were first 
turned strongly to one side, and then she squinted. 

Twice has Goodhart seen hemi-anaesthesia with hemi- 
plegia in boys of eleven or twelve. In the case under his 
own care he was at first disposed to think that there might 
be some actual lesion, notwithstanding the strong probability 
which experience teaches that, with complete hemi-anaes- 
thesia and hemiplegia, the condition is a functional disturb- 
ance only. But he subsequently learned that the child was 
a regular vagabond, and his previous history, his habits, 
and the variability of the paralysis, made it conform to rule 
rather than to exception. 

The boy was twelve years old, with a neurotic family his- 
tory. The paralysis came on in a night, four months before. 
He had been a sharp boy, and had reached the highest class 
in the school ; but he had become dull and odd in manner, 
staying out all night, and being dirty in his habits. He had 
a markedly neurotic aspect — very dark, with deep-set eyes 
and small cranial development. He had a cunning appear- 
ance, yet had no air of imposture about him. His face was 
paralyzed on the right side, and the tongue deviated to the 
right side. The right arm was paialyzed, the extensors of 
the forearm most markedly so, and the wrist dropped as in 
lead-poisoning. He made evident efforts to move it when 
told, but was obliged to call in the aid of the opposite hand. 
There was less decided failure in the leg, but when he 
walked his toes caught the ground in putting the foot 
forward — the knee was flexed, the heel drawn up, and the 



FUNCTIONAL NERVOUS DISORDERS. 545 

limb moved clumsily, as from want of harmony between 
the co-acting muscles rather than from actual paralysis, but 
the extensors obviously had the worst of it. The loss of 
sensation was complete, and thoroughly distributed to the 
right half of the body, mucous membrane as well as skin. 
The knee reflex on the paralyzed side was markedly exag- 
gerated. He was partially undressed for examination, and 
as I watched him in attempting to re-dress, whilst we went to 
the other children in the ward, he was evidently quite help- 
less as regards the right arm. The paralysis both of sensa- 
tion and motion — but the former far more than the latter 
— varied much from day to day ; and sometimes his special 
senses suffered, and he would become completely deaf on 
the right side, unable to smell with the right nostril, and 
wholly blind with the right eye. He could not then tell 
light from darkness, nor did he flinch when the finger was 
brought close to his eye. There were no morbid ophthal- 
moscopic appearances. Unfortunately he became so unruly 
and dirty that it became necessary to discharge him, and he 
was thus lost sight of, not much better than when admitted. 

Hysterical contracture will also be found sometimes in 
girls of eleven or twelve. Quite lately, a case of this kind 
has been under the author's care. It was speedily cured by 
keeping the affected arm firmly bound to the side, and com- 
pelling the use of the other. 

Headache is very common in children, from six years old 
and upward, and it arises from all sorts of causes. It is 
usually frontal and associated with sickness ; sometimes it is 
one-sided, over one or other frontal eminence, and occasion- 
ally disturbance of vision accompanies it, as in the megrim 
of older patients. 

It is not easy to distinguish between the different forms of 
headache. Most commonly the child is said to be subject 
to sick-headache ; but, when the case is investigated — in 



546 DISEASES OF CHILDREN. 

one the ailment may be due to anaemia; in another to 
indigestion or constipation ; in another it is a trait of a child 
of rheumatic parentage ; in another, the result of hyper- 
metropia. To arrive at an opinion in any case, it is well 
first of all to examine the eyes by the ophthalmoscope so 
as to eliminate the last-named condition. A large number 
of children are hypermetropic, and when they begin to tax 
their eyes for reading the strain upon the power of accommo- 
dation becomes excessive, and frontal headache arises, which 
may or may not be associated with internal strabismus. 
The headache is usually a supraorbital one, and the letters 
run one into the other as the child reads. It is not unim- 
portant to add that these cases are often distinctly worse 
when the health is deteriorated from any cause. The 
strabismus may, indeed, only be noticeable at such times 
— like the decayed tooth, which, though always decayed, 
aches only now and again, in response to impairment of the 
general health. In another large group of cases, the 
children are badly nourished and anaemic. The relation of 
gastric disturbances to headache is more open to question ; 
for it is certain that in many, perhaps most, cases of megrim, 
the stomach and brain react upon each other, and food 
will unquestionably excite an attack of headache, as a 
worm or other intestinal irritant will excite a convulsion. 
Headache is sometimes troublesome in girls at puberty, 
and is associated with catamenial irregularity and back- 
wardness. The headache of brain disease is likely to be 
occipital, unless it be due to meningitis, when it is general. 
Sick-headaches usually manifest some periodicity, though 
it may be but an irregular one. They are oftentimes 
attributed to food, and they are associated with vomiting. 
The headache is frontal, often of throbbing character about 
the temples. The head is hot, and there is often some 
intolerance of light, or some hyper-sensitiveness of hearing. 



FUNXTIONAL NERVOUS DISORDERS. 547 

The victim is the subject of a terrible malaise, and for the 
time being only wishes to be let alone, and longs for sleep. 
The tongue is usually clean, the temperature normal, and 
the pulse not quickened. The duration of sick-headache is 
variable. It generally subsides in sleep, and lasts but a few 
hours. Occasionally the vomiting is severe and repeated, 
and the child is out of sorts for some days. The anaemic 
headache is less localized, more continuous, and perhaps less 
often associated with sickness. In most cases of headache 
the bowels are irregular. 

The ailment being a common one, there is some risk ot 
overlooking the headache of organic disease. It will be 
well, therefore, to remember that bad headache sometimes 
ushers in typhoid fever — one of the common diseases ot 
childhood — and that the headache of meningitis is usually 
associated with pyrexia and constipation, as well as its own 
more special symptoms. The hypermetropic headache 
may be suspected if there be hypermetropia, and the 
anaemic, rheumatic, and other forms must be diagnosed by 
reference to the appearance of the child, its past history, its 
family history, etc. 

Headaches are usually troublesome, for several reasons. 
They are common, are not thought much of, and their excit- 
ants are not therefore avoided as they might be; more- 
over, they are not immediately amenable to remedies — in 
many cases they hardly appear to be influenced at all — and 
the child slowly " grows out of them." The hypermetropic 
headache must be treated by the ophthalmic surgeon (not 
by the spectacle-maker), who will see that any anomalies of 
refraction or in the shape of the eyeball are properly cor- 
rected by carefully adjusted spectacles. Apart from this 
special form, all headaches are likely to be rendered less 
frequent by the prolonged use of such drugs as arsenic and 
iron, but they must be given for some weeks continuously 



54-8 DISEASES OF CHILDREN. 

if they are to produce much effect. In the headache of 
girls at puberty, perhaps iron, permanganate of potassium, 
and bromide of ammonium are most useful. For the attack 
itself, bromide of potassium may be given ; it is sometimes 
successful in relieving the throbbing forms of sick-headache. 
Guarana and tonga are sometimes useful, although not 
easily administered. Guarana may be administered as an 
elixir (Martindale), the tincture of guarana being mixed 
with equal parts of simple elixir, and half a teaspoonful or a 
teaspoonful given, in water, for a dose. But, upon the 
whole, sleep is the best restorative, and arsenic the most 
reliable tonic for keeping the attacks at bay. 

21. Idiocy is met with at any age, from a few weeks after 
birth onward. Imbecility is a condition of many grades. 
In some there is but slight departure from the healthy con- 
dition ; some are for long unable to walk or talk ; the worst 
cases have no natural sense of any kind. Twice only has 
the author seen anything in the nature of cretinism among 
his own cases. Of nineteen cases, five were uncomplicated. 
In one there was a peculiar condition, which could only be 
denominated speech idiocy. The child, aged five, seemed 
fairly intelligent, although mischievous. She appeared to 
understand in a measure what was said to her, but her 
utterances in return were quite unintelligible. Two were 
deaf mutes; five were more or less amaurotic (only one of 
these had had fits); one had white optic discs; one reti- 
nitis pigmentosa ; one a peculiar stippled condition of cho- 
roid (? choroiditis) ; and the other two were amaurotic, 
without visible change in the fundus oculi ; four others had 
had fits ; and two were cretins. 

Infants are often brought for an opinion as to their men- 
tal capacity, because they take less notice than is natural, 
or are too placid, or make no attempt to talk, or walk late, 
or what not. In most of these cases the mother is over- 



idiocy. 549 

anxious, and there is nothing wrong. The head is of good 
shape, the child is attracted by slight noises, and will evi- 
dently follow, though perhaps fail to make for, any glittering 
object which is offered it. Some children develop slowly, 
but, provided that some progress is made, it is unnecessary 
to conjure up imaginary possibilities. On the other hand, 
it occasionally happens, too, that blind fondness refuses to 
recognize idiocy when the mere shape of the head renders 
it patent to every one but the parents. 

Idiocy may be either congenital or acquired. The con- 
genital cases are likely to be microcephalic. Acquired 
idiocy is common after convulsions. It is in many cases 
impossible to say whether the two forms are alike due to 
some cerebral lesion or whether the one is dependent upon 
malformation rather than disease ; but in some cases the 
history of sudden convulsion, one or many, is precise, as 
also that progressive impairment of intellect has followed. 
Idiocy may be compassed in a variety of ways at this early 
age, in some by lesions which deprive the child of important 
channels for the acquisition of knowledge and experience, 
such as sight and hearing, in others by damage to the 
cerebral cortex ; but the frequency with which convulsions 
are spoken of as an initiaj symptom seems not unlikely 
to point to meningeal or inter- arachnoid hemorrhage, and 
subsequent pachymeningitic changes, as a common method 
of causation. Other cases there are, called by Langdon 
Down " developmental," where the disease comes to chil- 
dren who have at first evidenced an average intelligence, at 
the period of the first or second dentition or at puberty. 
Such children develop up to a point, and as a result, per- 
haps, of a fit, or some greatly impaired nutrition, such as 
may show itself by chorea, they become imbecile, and the 
brain undergoes no further development. 

Cases of this kind, and congenital idiocy probably, find 



550 DISEASES OF CHILDREN. 

a predisposing cause in consanguineous marriages and in 
alcoholic excess in either parent. The developmental form 
is possibly sometimes to be attributed to masturbation. The 
morbid anatomy of the brain of idiots is one of considerable 
variety. The brain may be very small, or the convolutions 
may be rudimentary or simple. One part or other may be 
absent or ill developed — the eyeballs and optic tract, 
perhaps, or some part of the basal ganglia, or one side 
or other of the cerebellum. And in the acquired forms, 
thick membranes, pachymeningitis, cysts, thickening or 
deformity of the skull, etc., may be found in respective 
cases. 

22. Cretinism, as commonly seen, is a disease which is 
endemic in certain parts of certain countries. In Europe, 
it abounds in Styria and the Tyrol, and it is not uncommon 
in the Swiss valleys, Savoy, and Piedmont. It is occasion- 
ally seen in England, in the dales of Derbyshire and York- 
shire ; but in this country it is more generally known as a 
sporadic affection. Happily it is not common. Those who 
have charge of large asylums for idiots see most of it, and 
Beach, of Darenth Asylum, has published some interesting 
cases. Fagge was the first in England to call attention to 
sporadic cretinism, in a very valuable paper in the " Trans- 
actions of the Royal Medico-Chirurgical Society." 

It is a curious and interesting disease, so strangely con- 
tradictory is it in its external form ; for in many respects 
age comes to the features in babyhood, while the blight of 
babyhood, in its weakness, imbecility, and puniness, settles 
upon the corporeal form, and withers the opening mind. 
The appearance of these cases is very characteristic. They 
cease to grow in very early infancy, and year after year 
they change so little, that the child of two or three remains 
much the same at eight or ten, or even much later. In the 
author's two cases, a girl of nine and a boy of fourteen have 



CRETINISM. 551 

hardly altered, the girl since she was four, the boy since 
three. They have a yellowish, chlorotic aspect, their skin 
is thick, harsh, and wrinkled, and the subcutaneous tissues 
in some parts seem almost cedematous, the eyelids being 
particularly puffy. The scalp is also noticeable for its harsh, 
scaly condition, and the scanty growth of coarse hair upon 
it. The head is flat and broad, the forehead small, the face 
large. The limbs are large, the hands and feet flattened out, 
the abdomen large and pendulous, the tongue seems often 
too large for the mouth, and lolls from the open lips and 
teeth ; the teeth are irregular, deficient, stunted, and decayed. 
The thyroid has usually been said to be enlarged, but in 
some cases of sporadic cretinism it has certainly been want- 
ing, and in others it has probably undergone atrophic or 
destructive changes. Attention, too, has been called to the 
existence of pads of adipose tissue in the triangles of the 
neck. They are often of considerable size, but it is doubtful 
whether they have any further significance than as a part 
of the general tendency which exists, both in these cases 
and in the sporadic cretinism of adult life, or myxcedema 
as it is called, for the development of an excess of subcuta- 
neous tissue. 

Causes. — Consanguinity in the parents and alcoholism 
have been thought to predispose to a degenerate state of 
nervous system which may develop into cretinism, or into 
other forms of idiocy. But from the fact that it is a disease 
which attaches to particular regions, it seems clear that 
geological conditions play an important part in its produc- 
tion, and of these the existence of magnesian limestone in 
the soil is generally considered to be the most important. 
It is said that infants are liable to become cretins if taken 
to reside in districts in which cretinism is endemic. 

The tendency which the same geological conditions have 
to produce goitre, and the frequent co-existence of the two 



552 DISEASES OF CHILDREN. 

diseases, have long been a matter of interest, and the re- 
lation between the two, a subject of speculative inquiry. 

A further point was made when Fagge showed from dis- 
sections that in some cretinous children the thyroid body 
is absent. We do not yet know the full bearing of these 
facts ; but of late it has been asserted by Kocher and others 
that cretinism has supervened in adult life upon extirpation 
of the thyroid ; and in one or two cases of myxcedema, 
which is a cretinoid state supervening in adult life, that have 
died and been thoroughly examined after death, the thy- 
roid body has also been found to be atrophied and diseased. 
One of Fagge's cases, a girl of eight, fell ill with what 
was supposed to be a second attack of measles, and although 
perfectly healthy before, she became a cretin after. Fagge 
remarked that, "taken with the fact that the thyroid body 
is congenitally absent in so many cretins, it certainly sug- 
gests the idea that the febrile illness led in some way to 
atrophy of that organ, and that this was the cause of the 
supervention of the cretinous state." These observations 
go to show that the perfect functions (not alone develop- 
ment, for the disease may apparently be produced after the 
brain has developed) of the brain are in some way depend- 
ent upon the integrity of the thyroid — a most important 
fact if it can be shown to be true. 

Morbid Anatomy. — The bones of the skull are thick, the 
sutures abnormally obliterated, and the various foramina 
are liable to narrowing. Great importance is attached by 
Virchow. to premature union of the basal sutures, by which 
it is not unreasonably supposed that the growth of the 
skull, and, therefore, of the brain, would be seriously inter- 
fered with. In a case under the care of Dr. Grabham at 
Earlswood and mentioned by Dr. Fagge in his work on 
medicine (volume I, page 775), the base of the skull was 
much altered in shape, the posterior clinoid processes being 



CRETINISM. 553 

at a higher level than the anterior, and the sella turcica 
exceedingly narrow — the clavus was horizontal, and the 
cerebellar fossae shallow. The condition of the long bones 
is also peculiar ; their cartilaginous ends being enormously 
out of proportion to the stunted shafts. 

The Diagnosis of cretinism, or of idiocy, can give but 
little trouble. 

Prognosis is bad in cretinism. In idiocy it will depend 
somewhat upon its degree. Down states that the worst 
cases are those of accidental origin. More is to be ex- 
pected to result from training in congenital cases, and 
which are prima facie worse looking, than in the possibly 
more hopeful appearance of the child who is imbecile from 
disease. 

Treatment. — With the exception that cretins must be 
removed from any place in which the malady is endemic, 
and taken to dry and porous soil, the treatment of all forms 
of idiocy is much the same. A diminished brain capacity 
is the malady ; to make the most of the little that is left 
is the aim of treatment. The individual is less highly 
endowed than ourselves; he is in a lower grade; he needs 
to be studied. He has to be educated, and it becomes the 
business of his instructor to instil habits of order, cleanli- 
ness, and obedience ; to discover his likes and dislikes ; his 
most sensitive nerve strands and centres, and generally to 
work along the lines of such senses as retain the most per- 
ception. Idiots must be educated objectively. They are 
to be made happy by every possible means. And to this 
end their surroundings must be pleasant; they must have 
a teacher whom they love ; and their eyes, ears, and hands 
must be taught to carry instruction. A knowledge of 
color and form can be brought home to them through the 
eye, and thus some of the fond memories and instant pleas- 
ures with which the beauties of Nature are associated ; 



554 DISEASES OF CHILDREN. 

music may be made to charm the ear, and, making reso- 
nance amid the trembling strands, tone into life some pulses 
of thought; while the hand, by judicious exercise, may be 
made apt for various arts. It is by the application of means 
like these, backed by indomitable perseverance, and a 
capacity for seeing in the but slow progress of the day or 
of the year a comparatively bright future, that a success 
that must be called wonderful has been achieved at such 
institutions as Earlswood and Darenth. The education of 
the weak-minded must necessarily for the most part fall to 
such as have especially qualified themselves and who are 
specially apt. Patience, perseverance, and ingenuity in the 
opening up of fresh channels of instruction are the great 
requisites, and a somewhat uncommon combination of 
mental endowments in the instructor is necessary to com- 
mand success. Nevertheless, these cases will, under favor- 
able circumstances, and with the requisite attention, improve 
much even in home life ; and this hope is to be strongly 
impressed upon the parents, or those who have the charge 
of such children, as the motive for that continuous training 
which alone can enable the child to make the most of its 
diminished capital of brain power. Medically, there is not 
much to say, but that little is important. Mens sana in 
corpore sano is old and true ; but here the converse is the 
more important truth, that the mind being feeble, the bodily 
nutrition and reparative power are equally feeble. Im- 
beciles require warmth, they require to live on a dry 
porous soil, to be guarded against sudden atmospheric 
changes, and to be fed well. Except in so far as idiocy is 
occasionally seen in an early condition, dependent upon 
brain disease, syphilitic or other, or upon some neurotic 
state, such as chorea, it does not call for any special* treat- 
ment in the matter of drugs. 

It is in one or other of these two conditions, idiocy and 



CHOREA MAGNA. 555 

cretinism, that pronounced mental disease comes perhaps 
most frequently under notice ; but there are other less defi- 
nite conditions which are far more common — children not 
idiots, yet low, cunning, mischievous, and tiresome. Moral 
insanity, West calls such aberrations, and a very good name 
it is. Others are stupid above measure with books, but 
sharp with their fingers, or with some sense or other. All 
these require to be carefully studied, for there are few who 
have not some doors open by which their moral culture 
may be raised if we will but carefully search for them. 

Another common form of neurosis is passion. A little 
excitement sends such children into a fury, so that they 
become dangerous to their playmates. More or less this is 
a very common form of mental disorder, and it is very 
closely associated with bodily disorders. The child is 
worse when it is poorly, and the outbursts of excitement 
tend to react upon the bodily functions, and thus to make 
their disorder worse. 

Some children are melancholic. One sees marked cases 
of this sort in boys and girls, the latter more often. Melan- 
cholic children are usually anaemic and haggard looking, 
and decidedly improved by good feeding and absolute rest 
of mind and body. If there be any difficulty in their taking 
a requisite quantity of food, they must be dieted strictly, 
and made to take what is ordered. Such are fit cases for S. 
Weir Mitchell's plan of treatment, which has been so suc- 
cessfully advocated in this country by Dr. W. S. Playfair 
for neurotic women. 

22. Chorea Magna, so-called, is also a mental disorder. 
It is not one that physicians see much of. It has many 
resemblances to some of the more frenzied states of hystero- 
epilepsy that are happily but seldom seen. The affected 
child becomes quite maniacal, and performs all sorts of 
antics ; dances, sings, declaims, or falls into a state of epi- 



55^ DISEASES OF CHILDREN. 

leptiform convulsion, or of cataleptic rigidity. It is a dis- 
ease which is likely to come on as puberty approaches, but 
sometimes occurs in precocious girls from ten years old 
and upwards. It must be treated by the administration of 
such drugs as iron, bromide of ammonium, oxide or sul- 
phate of zinc, and arsenic, the patient being under judicious 
management away from her friends. 

23. Chorea. — The study of chorea may be begun by the 
description of a typical case, which was not long ago under 
Dr. Goodhart's care in Guy's Hospital; and which has the 
advantage of an exceedingly good report by the clinical clerk, 
Mr. Braddon. It is that of a girl aged eleven years, a thin 
anaemic child, with thick red hair and vacant expression. 
She had never been ill, but was always considered delicate. 
Her father was killed by an accident eighteen months before 
her admission ; twelve months later her brother died ; and 
eight weeks before her present illness, she, a girl of eleven 
only, had to " nurse " her mother through an attack of 
rheumatic fever. During this time she had complained of 
pains in her limbs and back, was feverish, and took to her 
bed for two or three days ; and from that time she grew 
duller, apathetic, and lost her cheerful manner. A month 
ago she was scolded by her mother for clumsily upsetting a 
cup, and it was then first particularly noticed that the move- 
ments of her right hand w r ere ill-conducted, and that she 
was always twitching the right side of her face. Her right 
foot next became unsteady, and these irregularities pro- 
ceeded gradually to constant convulsive jerks and twitches 
of either, but more particularly of the right side of the 
body. Five days before her admission, a game-cock flew 
at her, and frightened her so that she moped by herself and 
was speechless ; and, till her admission, her spasmodic per- 
formances had increased in violence, and her talking and 
gestures had become unintelligible to her mother. 



CHOREA. 557 

She lies in bed with her head twisted on one side, and 
rapidly changing in position if she is observed. She opens 
and shuts her mouth, twitches up its corners, jerks her head, 
and snatches the eyes irregularly from side to side. Her 
arms are thrown constantly before her on the counterpane, 
with a tendency to place her fingers in any position but 
apposition, the forearm being mostly in a position of over- 
pronation. The left arm is less distorted in movement 
than the right. When asked to pick up a pin, an irregular 
series of muscular actions take place, tending ultimately to 
the desired result, but in which there is a noticeable tendency 
to the use of the adductors in excess of the abductors, 
and the pronators before the supinators. When asked to 
sit up in bed, she does so by an alternating use of opposite 
muscles, working upwards spirally like an eel, her legs gen- 
erally crossed, but not much subjected to the irregular move- 
ments ; the abdominal muscles take a fair share in the gen- 
eral jactitation of the body. When spoken to, she first cried 
and then laughed ; she generally laughs, and at the same 
time the movements increase. She takes some time to gather 
head to answer, which she generally does with stuttering 
articulation and explosive manner. There was slight clonic 
response in the calf muscles on stretching the tendons, and 
the extensor tendon reflex was good, the superficial epigastric 
reflex being exaggerated. The heart sounds were sharp- 
sounding and unduly pronounced, but quite clear; the pulse 
irregular, soft, ninety-six per minute ; a bruit dc diablc over 
the veins of the neck; the bowels were rather confined, the 
tongue flabby and rather furred. She was treated by ten- 
minim doses of liq. arsenicalis, and kept in bed and fed well, 
and under this routine she soon became much quieter, and 
a fortnight after admission she was allowed to get up. On 
the sixteenth day she was still considerably choreic in both 
arms, and her heart was still irregular; a decided but remit- 
47 



55§ DISEASES OF CHILDREN. 

ting short systolic whiff had come at the apex, and another 
in the third left interspace near the sternum and over the 
third rib. The second sound was very accentuated, and the 
closure of the valves could be felt in the second space. 

If the student studies this report, he will find not only a 
truthful account of a case of chorea, but also in every fea- 
ture that is described one of the common occurrences of the 
disease, whether it be the family history, the antecedents, the 
appearance of the child, or the distribution of the movement, 
the posture assumed, the state of the mind, the behavior of 
the heart, or any other of the many small deviations from 
normal behavior of the viscera, which together make up the 
disease. He may learn from it that chorea is associated 
with rheumatism (a fact, however, which is disputed by one 
of the first authorities upon the subject), both by heredity 
and by the patient having suffered herself from that disease 
(the mother had had rheumatic fever, and in all probability 
the child herself). It is typical in the sex — chorea being 
far more common in females. Next it illustrates the rela- 
tion of the disease to fright, worry, and overwork. All 
these things are powerful immediate provocatives of choreic 
movements, but they are, in all probability, not by them- 
selves sufficient, in the absence of rheumatic strain or other 
predisposing nervous weakness. Next it may be noticed 
that the onset is slow. She is first dull and apathetic, next 
she becomes clumsy with her right hand, and the right side 
of her face is twitched, and so on, till the whole right 
side is affected, and her speech grows unintelligible. Her 
posture in bed is characteristic. Over and over again a 
choreic child will lie in bed, with head, and perhaps body, 
twisted to one side, in the condition of pleurosthotonos, 
and then change suddenly to an exactly opposite curve. 
How often, too, does a choreic child lie extended in bed, 
making all sorts of grimaces, with " its arms stretched out 



CHOREA. . 559 

on the counterpane," with its fingers pointing in all direc- 
tions but the natural one of " setting " toward each other, 
and the forearms and arms so rotated inwards and pronated 
as to make the palms look outwards. The crying and 
laughing when spoken to, the attempts to protrude the 
tongue, ending in its sudden appearance and as quick 
retraction, a flash of successful effort, an accidentally- 
conducted message amid the disturbance of the storm ; and 
lastly, to conclude this preliminary sketch, he may learn 
from it the not uncommon condition of the heart — that its 
action is irregular, and that, in the course of the disease, 
there is likely to appear a soft, systolic apex murmur, the 
characteristics of which are not sufficiently pronounced to 
enable one to say whether there is any organic disease of 
the valves or not. 

To define chorea is impossible ; but Sturges has hit 
upon a definition which is picturesque and sufficiently true 
to the purpose when he says that " chorea consists in an 
exaggerated fidgetiness." This description is a valuable 
one, because it will serve to convey the fact that chorea is a 
disease of varied degree. Sometimes it is so slight that all 
that can be said is that this or that child is an unusually 
restless one. It makes grimaces, or has peculiar finger move- 
ments, or it can never sit still, and so on. Fidgety children 
require watching ; more violent movements may come on 
at any time under favoring circumstances, and then they 
have chorea; but it is merely a question of degree. As re- 
gards the movements, they are excessively irregular ; they 
are as though the nervous current played about among 
the nerve-wires, and only now and again, by some deter- 
mined flash of the sensorium, does the correct message find 
its way. But the disease tells most upon such muscles or 
groups of muscles as are most varied in their action — most 
under the influence of emotion, some say — and thus the 



560 DISEASES OF CHILDREN. 

muscles of the face and arms are those which suffer the 
most marked contortions. 

Chorea often affects one side more than the other, when 
it is called hemichorea. The left side, some affirm, because 
the left arm and hand are less under control than the right ; 
the right side, others say, for reasons presently to be men- 
tioned. When the disease is one-sided, it not uncommonly 
assumes the form of paralysis, and choreic children are often 
brought for treatment because one arm is paralyzed. The 
twitching finger, the shrug of shoulder, or the grimance usu- 
ally reveals the nature of the disease without trouble. But 
although chorea, more marked on one side than the other, 
is very common, hemichorea, in the sense of the movement 
being entirely confined to one side, is very rare, we must 
agree with Sturges that such a condition is almost unknown. 
Chorea is essentially a general disease, an exaggeration of a 
faulty habit of control, and, although most decided here and 
there, is present to some extent everywhere. In fifty-four 
cases Goodhart has particularly noted the distribution. In 
thirty-four it was general ; in thirteen more on the right 
side ; and in seven only, more on the left. But there is no 
doubt that the one side or the other are less often promi- 
nently affected than this, for while most of the unilateral 
cases are noted, no doubt no definite statement has been 
thought necessary in many that have been generally dis- 
tributed, and it is probable that as regards the total number 
of the author's own cases (141) those in which the disease 
is mostly confined to one side would not have to be materi- 
ally altered. It will be noticed that it does not concide with 
the author's experience that the left side is the more prone 
to suffer unduly. 

The evidence of cerebral disturbance varies much. Not 
uncommonly choreics look completely imbecile, and they 
mostly laugh and cry from trivial causes and in a peculiarly 



CHOREA. 56l 

explosive manner. But it does not appear that the chorea 
is dependent upon any definite cerebral disease, for it often 
goes with a brain which gives but little evidence of disturb- 
ance, and in others imbecility and movements improve 
together rather as the bodily health improves. In a girl, aet. 
eleven, lately under notice, it was remarkable how the disease 
seemed to resist all treatment for some weeks, when sud- 
denly, almost in a day, the child improved in appearance, 
the movements ceased, she began to get fat in the face, and 
then progressed uninterruptedly to recovery. 

The history of chorea as regards its course is often one of 
much monotony, and for this reason perhaps in general 
practice it often fails to obtain the requisite medical super- 
vision. It is difficult to say when chorea ends, and, conse- 
quently, to fix its duration. To be once choreic is to be 
always so to some slight extent, and, therefore, when the 
more violent movements are controlled, there is yet a 
lesser range which is still choreic, and which must make 
one cautious in affirming a cure. It is no uncommon his- 
tory for such cases to run on for two or three months, 
although when they are taken into hospital they almost 
always rapidly improve. But this is only up to a certain 
point ; they then remain stationary, and the lesser move- 
ments of the choreic are often exceedingly troublesome. 

Six to ten weeks is usually given as the duration of the 
disease. 

Lingering, however, as chorea is, in childhood it com- 
monly gets well. It is more liable to be fatal as puberty 
commences. Nevertheless, death-tables do not show this 
very well, because the disease is so much more one of child- 
hood than of adolescence, and although relatively the death- 
rate is small, under fifteen, the aggregate equals that of the 
chorea of adolescence. By the records of Guy's Hospital, 
it appears that twenty- eight fatal cases of chorea have oc- 



Years, . 


5 


No., . . 


i 


Years, . 


15 


No., . 


1 



562 DISEASES OF CHILDREN. 

curred in the last thirty years, the respective ages of the 
cases being as follows : — 

7 . . 8 . . 11 . . 12 . . 13 . . 14 

5.. 1 . . 3 . . 1. , 2 . . 1 

. 16 . . 17 . . 18 . . 19 . . 40-50 

1.. 1. .5. .2. .2 

1 pregnant woman, exact age not stated. 
1 younger, not stated. 

The author has had two fatal cases in young children, of 
which he gives the notes. They very well illustrate the 
fact that when a fatal event ensues it is usually by the 
supervention of high temperature, rapid emaciation, and 
exhaustion — sometimes by coma. And, at any time, if the 
disease is complicated with much peri- or endo-carditis. 

A boy, aged five, was apparently in perfect health till 
eight days before his admission, when he slipped down stairs. 
He did not appear to be much hurt, and had a good night 
afterwards. But the next morning there was some loss of 
power in his hands and difficulty in swallowing. Soon after 
he began to scream at intervals during the day and occa- 
sionally at night. He had had pertussis and measles, but 
not acute rheumatism, nor was there any history of rheu- 
matism, so far as could be ascertained, in his family. He 
was in an irritable condition, resisting examination, but 
quite sensible and answering questions. He stared about 
in a vacant way, and his face, arms, and legs moved in a 
choreic manner. He swallowed without difficulty, and there 
was no paralysis of the ocular or other muscles. His left 
knee was a little swollen and painful, and a loud systolic 
bruit was audible at the apex, and another, less marked, at 
the base. No subcutaneous nodules could be found. He 
was kept at perfect rest in bed, and fed well, an ounce 
of brandy being ordered likewise. But the temperature 
gradually rose to 103 , the movements became more 



CHOREA. 563 

marked, and deglutition was very much impaired. He was 
then ordered salicin gr. v. three times a day, and he was 
sponged occasionally ; but he continued to sink rapidly, 
notwithstanding the administration of nutrient enemata, 
and subsequently of strong liquid nutriment, administered 
by catheter passed into the oesophagus through the nose. 

At the inspection there were general early pericarditis, a 
large fringe of vegetation round the mitral orifice, and 
smaller fringes on the aortic cusps. There was some 
broncho-pneumonia at both bases. The brain and spinal 
cord were apparently quite healthy. 

The other case was a girl of seven ; in some important 
particulars very similar ; there was the same, but more 
marked, rise of temperature; the same inability to swallow 
as the case progressed. 

Rosa L., aet seven, was admitted on October 14th, 1881, 
and died on November 8th, 1881. The parents are healthy. 
They have never had rheumatism, but the maternal grand- 
father was rheumatic. Of three other children, one has had 
acute rheumatism twice. During the last six months she 
has complained of pains in her knees, which have never 
been swollen, and also of occipital headache. Fourteen 
days ago she became very excitable, and her hands began 
to twitch. She became gradually worse, and now the move- 
ments are universal and she cannot stand. There is no 
history of fright, but she passed a worm a foot long ten days 
ago. 

When admitted, she had severe general chorea — not 
marked on one side more than the other — without fever, 
and with normal heart sounds. She was ordered a tea- 
spoonful of aq. chloroformi ter die, broth diet, and was kept 
in bed. She did not improve, and, eight days after, her 
diet was increased by two pints of milk, and six drops of 
liq. sodii arseniatis in glycerine and water were ordered. 



564 DISEASES OF CHILDREN. 

Her milk was increased to three pints on the 28th, or two 
days later. 

The temperature, till now normal, began to rise, and on the 
30th reached 102. 8°. She became very restless, the move- 
ments almost continuous, and she became unable to swallow. 

Nov. 3. — Decidedly worse. She is emaciating. Temp. 
103. 8°. The movements have eroded the skin of the back, 
and she was slung in a hammock. Subsequently some 
purpuric blotches appeared on her legs, she became coma- 
tose, and died on Nov. 8th, with a temperature of 105. 4 . 
She was bathed before death to reduce the temperature, but 
without any appreciable result. 

Medicinally, succus hyoscyami and chloral were adminis- 
tered towards the later days of the illness. 

The inspection showed no morbid appearances, except in 
the heart and kidneys. There were subserous petechias all 
over the former, especially on the posterior surface of the left 
ventricle. The edges of the mitral valve were roughened, 
and to these were attached fibrinous warty vegetations the 
size of a pea. The kidneys contained infarctions. 

Of the thirty fatal cases, twenty-five were in females. 

Morbid Anatomy. — With one exception, chorea has no 
morbid anatomy. There is no one lesion of constant stand- 
ing, save the fringes of vegetations which occupy the edges 
of the aortic and mitral valves ; but endocarditis, in the form 
of vegetations, is present in the greater number of cases. 
Of the fatal cases already recorded (thirty in all), these were 
present in twenty-eight, doubtful in one, and absent certainly 
only once. Their absence is quite the exception. The 
mitral was affected alone fifteen times ; both aortic and 
mitral valves nine times ; the aortic valves alone four times ; 
and pericarditis occurred with the endocarditis six times. 

The constancy of these little growths upon the edges of 
the valves has led to a very direct and simple pathology for 



CHOREA. 56£ 

chorea, in the suggestion that it is due to embolism. The 
vegetations are, it is supposed, washed off the valves and 
carried into the smaller branches of the cerebral arteries, 
and thus produce local anaemia, mal-nutrition, and degenera- 
tion of the cerebral cortex and ganglia, which lead to the 
loss of control over the muscles. In favor of this view it is 
said that the disease is often one-sided, and most often right- 
sided, as is the case in hemiplegia due to embolism, and 
due, it is thought, to the straighter course the arterial pas- 
sage offers to the transit of emboli to the left side of the 
brain than to the right. Secondly, in capillary embolism 
lies a rational explanation of the imbecility which so often 
accompanies the disease ; and lastly, that the smaller vessels 
have actually been found to be plugged in chorea by several 
competent observers. 

But these various arguments are traversed in several ways. 
The preponderance of a right-sided affection, for instance, 
is denied by many ; a strict limitation of the disease is un- 
doubtedly rare. Supposing that one or other side suffers 
more severely, the affection is, nevertheless, present in other 
parts to. a less marked degree. And as to the unilateral 
intensity, Sturges, whose experience is very large, and whose 
observation has been so careful and candid that it may well 
outweigh much that might otherwise point to a conclusion 
opposed to his, gives the seat of onset as thirty-six for each 
side. Pye-Smith, in an analysis of the cases in the clinical 
records of Guy's Hospital, 1870-72,* gives thirty-three cases 
of tolerably limited hemichorea, fifteen right and eighteen 
left. Out of fifty-four of Goodhart's cases, in which the 
distribution was carefully noticed, it was right-sided in 
thirteen, and left-sided in seven ; and he thinks it probable 
that larger numbers would make it still more evident that 

* Guy's Hospital Reports, ser. iii, vol. xix. 

48 



566 DISEASES OF CHILDREN. 

it has but little tendency to attack one side more than the 
other. Take, next, the fact that choreic children are, almost 
invariably, peculiarly and recognizably fidgety or nervous 
— physiologically unstable — and that the exaggerated or 
pathological condition may be followed up step by step in 
association with excess of wear and tear, or in response to 
some sudden nervous shock. Next, if chorea be due to 
embolism, why is the heart-murmur produced late in the 
disease ? And, lastly, it may be asked : Why is chorea so 
uncommon in adults ? Embolism is common enough. 
Why is it relatively infrequent in children when compared 
with the frequency of endocarditis ? It can hardly be 
doubted that acute endocarditis, from whatever cause aris- 
ing, leads not unfrequently to capillary embolism, though 
not, it would appear, to chorea. Considerations such as 
these make one feel sure that the theory of capillary embol- 
ism is inadequate to explain the large number of cases of 
chorea, and we are quite prepared for what is found to be 
the case, that, opposed to such existing facts in favor of 
embolism, is a large body of negative evidence, where the 
vessels have been examined without result. It seems that 
a study of this disease leads to the conclusion that it is one 
unas .ociated with any recognizable structural change in the 
nervous system — that it is, in fact, a functional disease. We 
see this in the antecedents of the child, both parental and 
individual — we see it in the disease itself, in the want of 
control, the emotional excitement, in some cases its rela- 
tionship to hysteria, and its all but certain tendency towards 
cure. Although its pathology can only be clothed in some- 
what vague language, yet that hypothesis accords best with 
the facts of the case, which supposes the existence of some 
depressed state of nutrition of the intellectual or governing 
centres. What the relation of rheumatism to chorea may 
be. is not known, but Dr. Goodhart believes that the rheu- 



CHOREA. 567 

matic taint, whatever that may be, points out the individual 
in whom it exists as one in whom various morbid nervous 
phenomena are likely to show themselves ; whose nerve 
textures, cerebral more particularly, are easily impoverished, 
which being inherently bad, or easily exhausted, discharge 
intermittingly, erratically and feebly. 

Chorea is far more common in girls than in boys — ninety- 
eight girls to forty-three boys, or close upon, but rather in 
excess of, two to two. If we take the statistics given by 
Hillier, See, Pye-Smith, Sturges, and Goodhart, 1374 cases 
in all, the proportion is as much as five to two. That it 
should be more common in females is only what was to be 
expected, seeing that it is a disease very closely associated 
with emotional disturbances, which are at all times so much 
more rife in the female sex. The disproportion becomes 
still more marked after twelve years. 

The age at which chorea is most prevalent is between 
seven and twelve, and there is no decided difference between 
boys and girls as to this. But above twelve it would seem, 
as has been pointed out by others, that the disproportion 
between girls and boys, already two to one, increases to 
three or four to one. The table annexed shows this at a 
glance : — 

Age, 3 4 5 6 7 8 9 10 11 12 13 14 Over. Total. 

Girls, 1 2 7 6 15 7 13 13 8 12 5 3 6 98 

Boys, 042246784131 1 43 

Total, .... 1 6 9 8 19 13 20 21 12 13 8 4 7 141 

The same facts also come out fairly w r ell in the heart dis- 
eases of the choreic, as seen in fifty-nine cases : — 

"3 4 5 6 7 8 9 10 11 12 13 14 Over. 
0330 13 3254733 13 

The season of greatest prevalence is the spring. It occurs 
with extreme rarity in negroes. 



568 DISEASES OF CHILDREN. 

Chorea is very apt to recur again and again in the same 
individual. In nineteen of Goodhart's cases it is noted as 
having recurred, and in several three or four times, and 
he has several times had the same child under treatment on 
more than one occasion. 

There is a tradition abroad that chorea is likely to be set 
up in healthy children when they are associated with the 
choreic ; and in the familiar fact that when one person yawns 
others in his company are likely to follow, we have an ex- 
ample of unconscious imitation, such as the communication 
of chorea might be supposed to be. But there is no paral- 
lelism between the two. For whereas yawning is a perfectly 
orderly sensori-motor action, chorea is an irregular combi- 
nation of involuntary movements on the part of muscles 
which are for the most part habituated to perform move- 
ments entirely under the control of the will. One cannot 
conceive of the choreic movements being elicited by any 
mere sensori-motor disturbance such as starts a yawn, be- 
cause the movements are of parts which are specialized, and 
as such want the control of any one centre. Thus, although 
choreic children in some numbers are admitted into the gen- 
eral wards of children's hospitals, instances of contagion are 
rare indeed. We have never seen such a case. West and 
others have recorded instances, and no doubt they occur 
occasionally, but the risk is not great; and when they arise, 
they do so probably because some choreically disposed child 
has become startled by the sight of the contortions of its 
associate. This is illustrated by the history of a case in the 
Evelina Hospital but a short time ago, a girl aged nine 
years. Her mother had chorea twice, once when ten years 
old, and again at seventeen, and seven years before she had 
had rheumatic fever. The child's father had had rheumatic 
fever. The first child had had rheumatic fever, followed by 
chorea, a year ago. The patient is the fifth child, and in 



CHOREA. 569 

February, 188 1, had rheumatic fever. In June, 1882, and 
February, 1883, she had chorea; the first attack was caused 
by fright, and now from this last attack a younger child has 
" taken " it. 

Chorea is not prone to occur in several of a family (the 
author has noted this only three or four times in his series 
of cases), nor is chorea, as chorea, transmitted in any large 
number of cases. In three cases only of 140 had it existed 
in one of the parents in former years. It is well known to 
be very liable to recur when once it has existed. In fifteen 
out of the 140 it was a second, in two a third, in one a 
fourth attack, and in one there had been many. 

As regards the heart disease of chorea, somewhat con- 
tradictory statements are made. The balance of opinion 
seems to turn in favor of the larger part of it being due not 
to organic but to functional disease. The author cannot 
agree with this : making all due allowance for muscular 
irregularities, and a consequent temporary valvular (mitral) 
incompetence — a condition which undoubtedly exists in 
some cases — we have still other facts to consider : e.g., that 
in fatal cases a fringe of vegetations, either upon mitral or 
aortic valves or upon both, is present in the majority of 
cases ; and that a considerable number of cases of heart 
disease have previously had no other disease than chorea, 
so far as is known (of 248 cases of heart disease in children, 
fifty-nine were attributed to chorea, fifteen, however, being 
due to disease the exact nature of which was somewhat 
doubtful); and that of choreic cases many in the long run 
suffer from definite valvular disease. Moreover, the non- 
existence of a bruit is no proof of the non-existence of 
disease. Goodhart has several times seen the mitral valve 
fringed with vegetations in chorea, when no bruit has been 
audible during life, and more than once fatal embolism 
under like circumstances. It is most necessary to impress 



570 DISEASES OF CHILDREN. 

upon the student that the disappearance of a bruit is no 
proof whatever of the absence of organic disease ; for if such 
cases are watched, they will many of them show subsequent 
signs, by disturbed rhythm and altered quality of sounds, 
that the changes in the valves are slowly progressing, and 
there is no doubt whatever that here is one of the sources 
of some of the many cases of mitral constriction that come 
under our notice. 

Nevertheless, one cannot altogether discard the notion 
of a functional affection of the cardiac muscle, Irregularity 
of action is a very common feature of acute chorea, and by 
this is not meant a necessarily violent chorea; for it is well 
pointed out by Sturges, in his very masterly and philo- 
sophical essay on this disease, that the violence of the 
muscular movements has no correspondence with the fre- 
quency of the heart affection, and it is well known that in 
chorea there is frequently an altered quality of sounds, or 
an alteration in the rhythm. The existence of such a con- 
dition has, indeed, not been without dispute, but there is 
probably no doubt about it. The cause has also been the 
source of much discussion. We cannot go far wrong in 
considering it as due to choreic disturbances of the heart 
muscle, and to be essentially the same as chorea of any 
other muscle. It is of little moment whether the effect be a 
paresis of papillary muscle alone, as some have contended, 
or a more general affection. It is only necessary to re- 
member that the younger the child, and the more recent 
the case, the more likely is it to be present. It chiefly con- 
sists in a want of keeping time, the beats following each 
other at irregular intervals, or in an excited, or sharp, or 
sudden systole, which is less sustained than natural. The 
chief interest of this condition in a practical way is, how- 
ever, the bearing that it has upon the previous question, 
that of the existence of organic disease ; and it must be 



CHOREA. 571 

admitted that, given muscular irregularity, valvular incom- 
petence — particularly, of course, of the mitral or tricuspid — 
is likely to follow. Some have even suggested that, if we 
allow this, then the vegetations found upon the mitral valve 
in cases of chorea are the result of such regurgitation, and 
a sequence such as this, as an occasional thing, is by no 
means improbable ; but allowing all this, and important as 
it all is as regards the question of the relation between 
rheumatism and chorea, it seems to be conclusively estab- 
lished that the issue of chorea, as regards the heart, is in no 
small number of cases organic disease. Goodhart's figures 
are as follows : * thirty-eight had permanent cardiac dis- 
ease; nearly all of them mitral disease; thirteen others had 
evidence of disease, but whether permanent or not is uncer- 
tain ; of seventy-eight cases in which the heart is noted as 
being normal, thirteen had certainly had rheumatism. 

In five-and-twenty cases of the 141 there was a distinct 
history of fright, and in six others the child was noticed to 
be unusually timid ; in other cases the disease commenced 
after a fit, some exanthem, over-work, etc. Taking the 
figures of Drs. Sturges, See, Hillier, and Peacock with these, 
we have 670 cases, with 224 of them due to fright or some 
nervous shock or strain. This, probably, is too low an 
estimate of mental shock, for of 126 cases taken from the 
collective investigation records, sixty-six cases were attri- 
buted to causes of this kind. It is worth remark that, 
although there is in so many cases a definite history of 
fright, the onset of such cases is usually slow, and thus it 
happens that it is difficult in many cases to see any relation 
between the supposed cause and the effect ; and doubtless, 
for the same reason, it happens that a cause such as this is 

* He does not here include any case of heart disease attributed to chorea, 
such as are some of the fifty-nine above quoted, but only such as he has 
himself seen in chorea. 



572 DISEASES OF CHILDREN. 

at times entirely overlooked. It is probable that one fre- 
quent cause of fright or nervous shock in children which is 
liable to be overlooked in this relation, is nightmare. Nerv- 
ous children are very prone to this affection, and nothing is 
thought of it ; but those who have experienced its horrors 
— the palpitating heart of the awakening, and the ecstatic 
relief which is then experienced, and remains with some for 
some time afterwards — will know that, to an unstable, 
nervous system, few things are more fitted to upset its 
balance and to induce chorea. And here, perhaps, may 
be introduced the question of the relation of chorea to rheu- 
matism, because, although in the majority of cases, perhaps, 
the latter stands to chorea rather as a constitutional element 
which predisposes, yet in some it precedes the chorea and 
introduces it, so to speak, and may thus be said to cause it. 
The facts the author has collected in relation to these matters 
are these : — 

Auto -rheumatic only, 14 

Auto- rheumatic with family history, . 25 

Rheumatic family history only, 50 

Gouty " " " 2 

Choreic " " " 2 

No history of rheumatism known, 37 

Not stated, 11 

141 

Thus, thirty-nine had had rheumatic fever, and fifty more 
had a history of rheumatism in some of their near relatives. 

There has been much discussion as to what the relation 
between these two diseases may be — whether, even when we 
take into account the average of rheumatism which belongs 
to every family, there is any abnormal frequency of rheuma- 
tism in choreic families. It will be sufficient to say that, 
after having gone carefully into the question, the author 
believes some thirty per cent, of families taken indiscrimin- 
ately are rheumatic, while for chorea the percentage is 



CHOREA. 573 

about sixty. Chorea is not always rheumatic — it is a com- 
mon method of nervous breakdown in nervous systems of 
unstable build, however produced ; and a choreic child may 
as well be the offspring of the epileptic, neuralgic, gouty, 
hysterical, or passionate, as of the rheumatic. Choreic chil- 
dren are often anaemic, often spare, as if they had been living 
badly, though this is by no means always the case. Sturges 
gives it as his opinion that the choreic child is not uncom- 
monly healthy-looking. 

Complications. — In severe cases the temperature may rise 
and become hyperpyretic ; when the movements are very 
violent and uncontrollable, the friction may produce nasty 
sores about the bony prominences or elsewhere. The 
severity of the paralysis or incoordination may expend itself 
upon the bulb, and the child be unable to swallow. Then, 
again, rheumatism, or one of its emissaries, endocarditis or 
pericarditis, may intervene — in what proportion of cases it 
is difficult to say ; probably not a large one. The Collective 
Investigation returns make it about twelve per cent. A 
case has already been mentioned where the chorea was 
succeeded by rheumatism, and as the latter subsided the 
chorea returned. The subsidence of chorea at the onset of 
rheumatism has been noticed by many observers. Fibrinous 
subcutaneous nodules, described by Drs. Barlow and 
Warner, are likewise found in some cases of chorea, as in 
acute rheumatism. The author has only met with them 
occasionally. Dr. Hillier records a remarkable case of this 
kind, certainly one of the most extreme that has ever been 
recorded. 

Prognosis. — This is, as a rule, favorable. The disease is 
troublesome rather than dangerous. Nevertheless, if the 
movements be very violent, if the temperature be high or 
slowly rises, if there be much peri- or endocarditis, or if the 
disease assumes the form of general paralysis rather than 



574 DISEASES OF CHILDREN. 

that of jactitation, the case must be regarded with anxiety. 
Certainly such cases as show much imbecility, with inability 
to swallow food, are dangerous, and require the most careful 
nursing. 

Treatment. — Choreic children are some of the most fre- 
quent attendants at the out-patient rooms of hospitals. In- 
quiry generally elicits the fact that they have been under 
treatment for some time, rather getting worse than better, 
and the patients have become tired of the want of improve- 
ment. This is not because chorea is not bettered by treat- 
ment. Take any or all these cases into hospital, and in a 
very few days a marked improvement will be manifest. It 
is often said there is no treatment for chorea — it gets well by 
itself. It does nothing of the kind. Many a child will drag 
on and on in a most miserable state at its own home for 
weeks and weeks, getting worse rather than better, which, 
when taken into a hospital, rapidly improves ; this is because 
many are content to give a choreic child this remedy or that 
of the many that have been recommended as valuable drugs, 
and there the treatment ends. Where lies the difference in the 
result ? Simply in this, that in hospital the child is kept in 
bed. Here is the first principle of treatment for all cases of 
acute chorea, the rest and quiet which bed offers. Other sub- 
sidiary details are by no means unimportant ; regularity in 
the administration, suitability in the quality, of the food, and 
attention to the action of the bowels, are not to be neglected, 
but rest and quiet come before all things. The child should 
be placed in bed, and, if the movements are violent, it must 
be carefully protected by padding the adjacent sides of the 
cot, or in very bad cases the child may be slung in a ham- 
mock. The bowels may be cleared out with some com- 
pound decoction of aloes — some glycerine being added, as 
recommended by Mr. Squire, to make it more palatable — 
or by some jalapine (one or two grains) ; and, if the sleep 



CHOREA. 575 

is bad, some Dover's powder, chloral, or succus hyoscyami 
may be given at night. A full milk diet is ordered, and 
some malt extract. As regards drugs, if the case be in any way 
acute or violent none need be given, but the child must be 
regularly shampooed twice a day for a quarter of an hour. 
This generally procures sleep; and by means of it, the good 
dieting, and the regular method of a hospital, great im- 
provement is soon manifest. When, under this treatment, 
the more violent movements are quieted, then is the time to 
commence with drugs. There can be no question that no 
one can claim any great advantage over another. Sulphate 
of zinc, gradually increased up to ten or fifteen grains three 
times a day, is, Goodhart thinks, a most useful remedy, 
though very old fashioned. Arsenic, gradually increased 
from three drops up to fifteen, or even more, is another ;. 
and with these, and iron and cod-liver oil, it is best to con- 
tent one's self. The value of arsenic is unmistakable. The 
editor's plan, when the patient can be watched, is to begin, 
from the first visit, with a small dose of Fowler's solution, 
three drops three times daily for a child of seven years, and 
gradually increase the amount by the addition of one drop a 
day until puffing of the eyelids or vomiting and gastric 
pain show that the limit of toleration has been reached. It 
should then be discontinued for a day, and afterwards re- 
sumed, the quantity being continuously kept a little below 
the maximum dose, until convalescence is established. Sub- 
sequently small doses of arsenic with iron must be given for 
a length of time to ward off a return. This method with 
attention to diet and the functions of the body has always 
proved most satisfactory, and often acted with wonderful 
rapidity. The more sedative drugs, such as the bromides, 
chloral, belladonna, hyoscyamus, conium, are of little real 
value, save as occasional draughts for sleeplessness, etc., in 
the early days. Veratrum viride has been recommended as 



57^ DISEASES OF CHILDREN. 

useful in chorea. The author has tried it, but seen no 
benefit from its use. In the last three years all the cases of 
chorea that have come under the author's notice in hospital 
have been treated as follows : They have been put to bed 
and allowed simply to rest, with good feeding, for two days. 
At the end of that time massage has been commenced, and 
special diet ordered, as follows: at 5.30 A. m., half a pint of 
warm milk ; 7 a. m., half a pint of milk and three slices of 
bread and butter (each slice an ounce in weight) ; 4.45 A. m., 
half an ounce of Kepler's Malt Extract in lemonade; 10 
A. m., massage (fifteen minutes), followed by half a pint 
of warm milk; 12.30 p. m., rice pudding, half a pint of 
milk, green food, and potatoes ; 4. 1 5 p. m., half a pint of 
warm milk, three slices of bread and butter, and an egg 
lightly boiled ; 7 p. m., half an ounce of Kepler's Malt 
Extract in lemonade ; 7.30 p. m., massage, followed by half 
a pint of milk. At the end of ten days or a fortnight, the 
bread and butter is increased to four slices at 7 and 4.15, a 
lean chop is added to the midday meal, and an extra pint 
of milk is distributed over the twenty-four hours. This diet 
was worked out by Dr. John Phillips, when resident at the 
Evelina Hospital, and Dr. Goodhart has found it very use- 
ful. This treatment is carried out for a fortnight or so, 
when the patient is allowed to sit up in bed, well supported 
by pillows, and perhaps play with toys. One should never 
be in a hurry to get the patient up, if the case has been in any 
way a severe one. The muscular strength appears to be 
recovered much better in bed, while it is remarkable how 
too early exertion will throw a case back. When up and 
about again, the arsenic or zinc and cod-liver oil should be 
continued for some time, and the child guarded from any 
great excitement in its play. A quiet convalescent home 
or change of air is often advisable, and the parents must be 
instructed to be careful of the child for a long time, as the 



CHOREA. 577 

remaining choreic movements are liable to become aggra- 
vated, under even trivial excitement. 

For choreic children, as a preventive, there is nothing 
like regular exercise, always short of fatigue. Gymnastics 
of all kinds are excellent, as are also exercises of any kind 
which tend to increase the voluntary control of the muscu- 
lar system. Thus, drawing, piano playing, or for younger 
children various kindergarten appliances, etc., are all useful, 
some for one case, some for another. 



PART VII. 

DISEASES OF THE ORGANS OF 
RESPIRATION. 



The physiological differences in the respiratory organs 
between the child and the adult are numerous, and, as re- 
gards the examination of children, they are by no means 
unimportant. The breathing is diaphragmatic in children, 
and as it is difficult sometimes to detect the movement of 
the upper part of the thorax, it is very necessary to have 
the chest thoroughly bare for the purpose of examination. 
Infants under two years breathe quicker than adults, thirty 
or more to the minute, but above that age the respirations 
are at about the same rate as in older people, though quick- 
ened by very slight disturbing causes. Children, also, 
breathe irregularly ; often paroxysmally ; after what may be 
called a modified Cheyne-Stokes type. The Cheyne-Stokes 
rhythm consists of a series of short but gradually lengthen- 
ing inspirations culminating in a deep-drawn breath, from 
which in a descending scale the respiratory movements 
flutter down to an elongated pause ; and this type of respi- 
ration, though much modified, and its sharper characteristics 
destroyed, may often be seen in infants. Pauses in respira- 
tion are a feature of childhood, and they are particularly 
marked when the child is crying. To auscultate a chest at 
such a time requires the greatest patience, the pauses are 
of such long duration, but the information gained from the 

579 



580 DISEASES OF CHILDREN. 

inspiration at these times is peculiarly valuable, each long- 
drawn breath after the temporary arrest is so full and deep. 
Infants and children not only breathe irregularly, but they 
breathe often with asymmetry. It is quite a common thing 
to find a child breathing fully, now with this side, now with 
that, and unless this is ever present to the examiner he will 
be not unlikely to make mistakes when it comes to be a 
question, as so often happens, of the nature of the disease ; 
nay, even of the side upon which it is located. This is due 
not to the muscular weakness, as some aver, but to the as 
yet imperfect education which is seen in all the muscles, 
whether of speech or of voluntary movement. Hence also 
the Cheyne-Stokes type of respiration, which is a paroxys- 
mal one. Children work paroxysmally, whatever the move- 
ment in hand. The nervous discharge takes place, and then 
comes* a pause — another discharge, and another pause — 
and so on ; and it is only as the nerve centres reach a 
higher state of training that the discharges are so regulated 
as to become more continuous. The author speaks of a 
little child, and such cases are not uncommon, who learning 
to talk will carry on a conversation to the full extent of his 
knowledge of words, for a few minutes, and then he be- 
comes quite fuddled for a while, and after a rest, on he 
goes again. The same child, if he is at all out of sorts, will 
stammer badly ; he becomes in fact aphasic intellectually, 
and his word-memory is for the time exhausted — or his ill- 
nourished brain loses its discharging force, and acts inter- 
mittingly. It is but little otherwise with the respiratory 
centres, they act irregularly, and soon become exhausted. 

A point or two connected with the physical examination 
of the chest may next be mentioned. Percussion is always 
to be gentle — apart from the reason that there is the likeli- 
hood of frightening the child, heavy percussion may lead 
to quite an erroneous conclusion. It will often elicit reso- 



DISEASES OF THE ORGANS OF RESPIRATION. 58 1 

nance, whereas the note is really dulled. This more readily 
occurs in dealing with fluid in the chest, and is probably 
due either to the heavy percussion displacing the fluid — 
bringing the stroke down upon air containing lung beneath 
— or else to the greater readiness with which, in young 
subjects, the stroke is transmitted to other and sounder 
parts of the lung. The chest of a child is said to be more 
sonorous than that of an adult — all that this means is that a 
more resonant note is more easily elicited ; and all that this 
can mean in turn is, that the percussion acts upon the lung 
more readily. Probably this is largely due to the more 
yielding nature of the ribs in young people, and to a thin- 
ner covering of soft parts over them. Due also to this 
ready yielding of the chest wall is the facile production of 
the cracked-pot sound so frequently elicited when percus- 
sing the infra-clavicular regions of the chest in healthy 
children. 

Again, it is not difficult to obtain a dull note which is not 
due to the condition of the lung underneath. A very little 
difference, for instance, in the level of the two shoulders 
will effect this, and the irregularity of respiration so notice- 
able in children will do the same. Therefore, in cases 
where the differences are slight, it is always as well to be 
cautious in our opinion, and probably to wait until a second 
examination has confirmed or negatived the original con- 
clusion. 

Percussion should be carried out by one finger laid firmly 
on the chest, and one or two fingers tapping it vertically, 
slowly and lightly. With these precautions, a good reso- 
nant note ought to be elicited anywhere, although, as in 
adults, the apices and scapular region vary much in differ- 
ent children. There is no reason for confining the examina- 
tion to the back, or for postponing percussion until after 
auscultation. There is but little difficulty with children if 
49 



582 DISEASES OF CHILDREN. 

they are left unrestrained and the percussion is gentle. It 
is usually well to commence with the examination of the 
back, so that, if the child be shy, the more important part 
of the examination may be conducted out of sight; but in 
a very large number of cases it is perfectly easy to even 
auscultate the front of the chest if the examiner sets to 
work with patience, and allows a child to play with the end 
of the stethoscope at intervals. Dr. Goodhart does not 
agree that auscultation is better conducted by the ear than 
by the stethoscope. The chest diseases of children are so 
apt to be partial in their distribution, and the accommoda- 
tion of other parts of the lung is apt to be so much more 
perfect, that it is very necessary to go over the chest care- 
fully inch by inch, to compare the corresponding sides of 
the chest, and to trace the intensity of the respiratory 
murmur from one side to the other. The ear covers too 
extensive a surface, and — taking in too much at a time — is 
thus likely to miss a small patch of consolidation or the 
deficient expansion which occurs so often. 

The student will have many a difficulty also with the 
quality of the respiratory murmur. He is usually told that 
the child's respiration is puerile — that is, that the inspiratory 
murmur is very harsh; the expiratory being but little 
altered. But, as a fact, his most frequent difficulty will be 
to know whether he is dealing with bronchial breathing 
which is the result of disease, or with that which is due 
only to a temporarily accelerated respiration. In young 
children the expiratory murmur in the upper two-thirds of 
the back is frequently of a bronchial nature — longer than 
it should be, higher pitched than it should be — and the 
question of the meaning of this can only be settled by 
close examination of both sides and an appeal to one's ex- 
perience. The observer should pay special attention to the 
pitch of the expiratory murmur, this being the best cri- 



DISEASES OF THE ORGANS OF RESPIRATION. 583 

terion of the nature of the sound. If it be not only long, 
but persistently of high pitch, it is well to be cautious. 
As another hint, it may be said : If the tubular breathing is 
of exactly the same quality on both sides, doubt your 
diagnosis, should you have decided that it means disease. 
It is so likely under these circumstances to be a tracheal 
respiration, transmitted, either from exaggeration on its 
own part, or too little damping by the vesicular murmur in 
a small chest. The editor thinks that puerile need not be 
confounded with tubular respiration. The former has for 
its distinctive character intensity ; in other respects there is 
no alteration. Tubular or bronchial breathing, on the con- 
trary, while it may be intense is otherwise anomalous. 
Thus the inspiratory element is shortened, there is a dis- 
tinct interval of silence between it and the expiratory sound, 
and the latter is higher pitched, louder, and more pro- 
longed ; features exactly the reverse of healthy breathing. 
As regards the necessity for careful comparison of the 
two sides of the chest, pleurisy and pleuritic effusion are 
very liable to mislead. Pleuritic effusion controls the 
action of the lung on the diseased side, but hardly other- 
wise alters the quality of sound, except at the apex, where 
it often compels tubular breathing ; thus it happens that 
listening over fluid, the respiration is soft and vesicular, and 
may seem natural, whilst an examination of the other side 
discloses what seems to be an excessively harsh and ab- 
normal sound, of doubly puerile character, if so we may 
express it. Thus, the report is made that the sound side is 
diseased and the diseased side healthy. This is quite a 
common mistake, and can only be avoided by paying 
exclusive attention to no one sign in particular, but by 
examining both sides of the chest throughout — not only 
by auscultation, but by percussion also — and by a careful 
scrutiny of the movements. With these few hints, we may 



584 DISEASES OF CHILDREN. 

pass to the consideration of special diseases, and there seems 
no reason for departing from the natural arrangement of 
working from above downwards. 

i. DISEASES OF THE NOSE. 

1. Coryza. — There are some children who are always 
"catching cold." This means that they begin to sniffle, 
and gradually a copious, glairy, and thin mucous discharge 
makes its way from the anterior nares. This state may 
last several days, the upper lip ultimately becoming 
excoriated and sore from the discharge and its frequent 
removal combined. During all this time the child is 
usually fretful, often feverish, thirsty, and without much 
appetite. Its nights are also frequently disturbed, for 
young children breathe so much through their nose, that 
the existing state of things prevents the natural respira- 
tion. Stand over the cot of a child with a " cold," and you 
will hear it sniffling away with quickened respiration, and 
then suddenly waking up and crying, tossing itself down 
on to the pillow again, and so on repeatedly. These cases 
run their course, so far as the nose is concerned, in two or 
three days ; but they are frequently succeeded by a cough, 
due, no doubt, to the extension of the catarrh along the 
mucous membrane to the posterior nares, tonsils, and fauces, 
and occasionally down to the epiglottis or rima as well. A 
cold, therefore, if severe, requires care, as at any time it may 
extend and set up a general bronchitis, or even laryngitis. 

Causes. — Whether colds are due, as is thought, to chills, 
or to atmospheric-borne germs, and so on, it would perhaps 
serve no useful purpose to discuss. But it is of practical 
import to remember that in many cases they are unques- 
tionably contagious. They are also frequent concomitants 
of dentition. 

Coryza should also be remembered as heralding often the 



OZ^NA. 585 

advent of measles, and as being sometimes associated with 
diphtheria, generally, though not always, with its more fatal 
forms. 

2. Ozaena. — In unhealthy children, particularly the scrofu- 
lous and syphilitic, nasal catarrh is liable to become chronic. 
The swollen mucous membrane becomes excoriated or 
deeply ulcerated, and in the most prolonged cases the bone 
may become exposed and die. In any case there is likely 
to bei ozaena, as the secretion is not merely mucoid, but 
purulent and bloody. It crusts upon the surface of the 
mucous membrane, becomes decomposed, and thus the fetor 
which is so characteristic and so loathsome. The sense of 
smell often becomes destroyed in the worst cases, a happy 
thing for the afflicted child. 

Treatment. — For simple catarrh very little treatment is 
necessary. Children from a few months old up to three or 
four years are those that give the most trouble, and perhaps 
from nine months to two years is the age at which colds are 
liable to be most severe. The child must be kept in one 
room at an even temperature, in bed if it is very feverish or 
fretful, and some saline may be given it, such as the citrate 
of potassium and a little fluid magnesia to act upon the 
bowels, if necessary. It is generally as well to give a sleep- 
ing draught at night of bromide of potassium and hydrate 
of chloral, five grains of the one, and half a grain or a grain 
of the other. West remarks that an intractable catarrh 
is sometimes cured by gray powder, even though there 
may be no evidence of the syphilitic taint, and the author's 
own smaller experience certainly corroborates this. In the 
chronic cases two ends have to be kept in view, the build- 
ing up of an unhealthy body, and the cure of the diseased 
mucous membrane. The local treatment is usually neglected 
in whole or in part. The parents will make their children 
take any quantity of medicine, but they will not take the 



586 DISEASES OF CHILDREN. 

trouble to secure efficient local applications ; and, unfortu- 
nately, local applications are of the first importance. The 
chief object of these is to keep the surfaces moist and sweet ; 
the disease is so troublesome, because the discharges crust 
on the surface and become offensive, and thus in the various 
movements of the nose the mucous membrane beneath the 
crusts and at their sides cracks and bleeds. Therefore an 
antiseptic must be applied to keep the parts sweet, and 
glycerine or oil added to it to keep them supple, ^com- 
bination of iodoform, eucalyptus oil and glycerine makes 
a nice and effective preparation : — 

R. Iodoform, £ss 

01. eucalyptus, f^ss-f^j 

Glycerine or 

Vaseline, q. s. ad ^ij or ^iij. M. 

SlG. 

An ointment in which vaseline is substituted for the glyce- 
rine may be used instead. The glycerinum boracis, or gly- 
cerine and boracic acid, are also useful preparations. But 
whatever be used, it is essential that it be applied freely and 
frequently, and this is not easy of accomplishment. Some- 
times astringents, such as equal parts of glycerine and the 
glycerine of tannic acid ; or that and sulphate of zinc, in the 
proportion of two grains to each ounce ; syringing with per- 
manganate of potassium, or with a borax and bicarbonate of 
sodium lotion, are very useful in older children. But the 
difficulty of local application is greatly enhanced, if not alto- 
gether impossible in many instances, in young children when 
the syringe comes to be used. The best way of syringing 
the nose is undoubtedly the hydraulic method — an india- 
rubber tube, leading from a small cistern or jug containing 
the lotion, and placed at the requisite height, plays the part 
of a siphon. The nose-piece is placed in the nostril, and a 
most perfect syringing is thus accomplished. But very 



OZ.ENA. 587 

young children are much frightened by this. The sensa- 
tion produced by the water in the nose is not pleasant, and 
some of the fluid runs down into the pharynx and interferes 
with respiration. Moreover, the operation, to do it properly 
and cleanly, requires the attention of three people — one to 
take the child, one to collect the water that flows from the 
nose, and the third to manage the douche. Therefore this 
treatment is not often carried out thoroughly, and it is neces- 
sary to trust to the thorough application by a brush of the 
remedies already mentioned. It is more practicable with 
older children ; and, with them, in addition to other meas- 
ures, a plug of iodized cotton-wool should be kept in each 
nostril. Failing any of these, some powdered boracic acid 
or benzine may be blown up each nostril with an insufflator; 
the operation being performed three times daily. For gen- 
eral treatment these children require good food, milk, cream, 
good air — particularly, bracing seaside air — and iodide of 
iron, cod-liver oil, maltine, stout, etc. 

While nasal catarrh is a trifling disease in children who 
have cut their teeth and been weaned, it is serious in nurs- 
ing infants, because it greatly interferes with alimentation 
by preventing nasal respiration, a necessity during the act 
of sucking. The danger is increased proportionately to the 
length of the attack. In obstinate cases, in addition to 
keeping the nose clean, by frequent swabbing, and thor- 
oughly anointing externally and internally with vaseline, it is 
well to make the patient wear constantly a light flannel cap. 
This plan was suggested by Dr. Charles D. Meigs, and 
sometimes it seems impossible to effect a cure without it. 
The cap should be removed slowly by cutting away a small 
piece at a time ; in this way the risk of a relapse from taking 
cold is avoided. 

The greatest perseverance is necessary in the treatment 
of ozaena. 



DISEASES OF CHILDREN. 

3. Epistaxis is a very common affection in childhood, and 
under conditions so varied that it is impossible to enumerate 
them all. Some children suffer again and again, whenever 
they are out of sorts, and this without any tendency to 
bleeding elsewhere. It is one of the commonest forms of 
hemophilic outbreak, and is also, as might be expected, a 
symptom of purpura from any cause. But perhaps it is 
more noteworthy as most frequently ushering in some acute 
disorder, be it one of the exanthemata, typhoid fever, per- 
tussis, acute pneumonia, or nephritis. 

It but seldom requires treatment save it be the outcome 
of haemophilia. Should it do so, the ordinary rules for the 
arrest of bleeding will at one suggest themselves — viz., ice 
to the nostrils, cold applications to the face and neck, and 
an inflation of tannin or matico snuff. 



2. DISEASES OF THE LARYNX AND TRACHEA. 

1. Pseudo-Croup — (Catarrhal Spasm). — " My child is 
very subject to croup," is a common tale of a mother to 
the doctor ; and as when a patient states that he or she has 
had a weak heart for years the medical man knows it to be 
the exception to find any organic disease, so here, the croup 
of domestic medicine is not the croup of the nomenclature 
of disease. Here is such a case : A boy, aged five and a 
half. He had a croupy cough three months ago, but got 
well in a day or two with some castor-oil. He had been 
quite well since until the day before he came to the hospital, 
when the cough returned. He had a loud brassy cough 
but no dyspnoea, and seemed otherwise quite well. The 
fauces were injected and the tonsils large. Some castor-oil 
was administered and a simple expectorant, and he was 
well in a day or two. The mother had alreaay lost one 
child by true croup — tracheotomy having been performed 



PSEUDO-CROUP. 559 

in the hospital — and she was therefore very anxious about 
the symptoms in this case. 

Henoch gives one of the best and most natural accounts 
of this affection. These children have usually been the 
subjects of repeated attacks of subacute tonsillitis, and they 
have enlarged tonsils. This condition of parts is usually 
accompanied by a more or less fleshy or swollen state of 
the palate and mucous membrane around the laryngeal 
orifice, and, as a result of some fresh but often slight 
catarrh, the ary-epiglottic folds become implicated, and 
some slight glottic spasm occurs. The child has usually 
had a slight " cold," perhaps wakes up suddenly at night 
with an ugly laryngeal, " brassy," " clanging," " croupy " 
cough, and perhaps with some temporary difficulty of 
breathing. This soon passes off, and it lies down to sleep 
again, breathing without discomfort, as soon as the fright 
of the awaking has passed off. This shows that the 
essential of the laryngeal trouble is spasm. The cough 
remains " croupy " for a day or two, and then disappears. 

Diagnosis. — This is arrived at by giving attention to the 
following features : The tendency to recurrence which these 
attacks evince; the preexistence of a cold or cough; the 
presence of large tonsils. In the attack itself, there is the 
absence of persistent inspiratory stridor, the unchanged cry, 
and the speedy subsidence of the momentary inquietude — 
nothing remaining, in fact, but the cough. All these things 
tell of the absence of any material obstruction, and in favor 
of a temporary laryngeal spasm, provoked by some catar- 
rhal state of the upper laryngeal orifice. At the same time, 
as a word of caution, it may be remarked that it is only 
natural to suppose that a condition of this kind, if neglected, 
might readily pass on into an attack of definite laryngitis ; 
and, no doubt, care is requisite lest, in treating such an 
attack as of no moment, we should find that an ex- 
50 



590 DISEASES OF CHILDREN. 

ceptional case might prove in the issue to be one of true 
croup. 

Treatment. — The croupy cough is one that invariably 
causes anxiety to the mother, and there is therefore but 
little risk of such cases being neglected. But the treatment 
should be decided, nevertheless. The child must be kept 
in bed until the cough has assumed a less menacing sound, 
and the room must be kept warm and the air moist by 
means of a bronchitis-kettle. Poultices or warm fomenta- 
tions are to be applied to the throat, and some expectorant 
is to be given frequently. Tr. benzoin, co., ^x; syrup, 
scillae, 5ss ; ext. glycyrrh. liq., 5ss ; aq. ad 5ij, may be 
given frequently, or some similar combination of expecto- 
rants. Subsequently, the treatment of the tonsillar enlarge- 
ment becomes again prominent, but this is discussed in its 
proper place. 

Catarrhal spasm should be used for this condition rather 
than the term pseudo-croup, not for the purpose of invent- 
ing a new name, but because it suggests the nature of the 
chief features of the disease, and because it is in harmony 
with a series of other spasmodic affections of the larynx 
which occur in childhood, and which may now be men- 
tioned. These are — 

[ . Direct Spasm, or crowing of con- 
vulsive nature, often rachitic. 

2. Reflex Spasm, or dyspnoea, due 
to spasm of the larynx, incited 
by enlargement of the medias- 
tinal glands. 

3. Infantile Spasm, or the crowing 
due to a congenital valvular 
formation of the upper orifice 
of the larynx. 

An objection may perhaps be taken to such an arrange- 



2. Laryngismus, 



DIRECT SPASM OF THE GLOTTIS. 59 1 

ment, that it exalts a symptom at the expense of the cause, 
and thus tends to destroy the more stable basis of classifica- 
tion — that of structural change. This has no doubt been 
felt by other writers, and has led them to treat of laryngis- 
mus among diseases of the nervous system. But laryn- 
gismus is so essentially laryngeal that in this symptom lies 
most of its interest, both as regards theory and practice. 

Direct Spasm of the Glottis is one form of laryngismus 
stridulus. The author calls it direct, because being largely 
associated with rickets, a complaint, which, by the convulsive 
affections which attend it, indicates a state of instability of 
brain — it may be regarded, so to speak, as centrally ordained. 

Some, perhaps, may still prefer to consider it a reflex 
spasm. But if so, the discharging stimulus is so frequently 
varied that it is impossible to fix upon it with any precision, 
and in the majority of cases all that can be said is — this is 
laryngismus, and the child is rickety. Of its convulsive na- 
ture, in many cases, there can be no doubt: it is frequently 
associated with convulsions, and not uncommonly with 
tetany as well. Of thirty cases of laryngismus now before 
me, eight had had convulsions, two others carpo-pedal con- 
tractions. Gee notes that nineteen of fifty of his cases had 
had eclamptic fits. Laryngismus is so frequently associated 
with rickets that, again appealing to Gee,* we find him 
stating that spontaneous laryngismus is always associated 
with that disease — forty-eight of his fifty cases being un- 
questionably so. Twenty out of thirty-four of my own 
cases were also rachitic. Goodhart has not noticed the 
association of laryngismus with craniotabes — that condition 
of skull in which the bones yield under pressure with the 
crackle of parchment — but this has been remarked upon by 
several observers. 

* " On Convulsions in Children" : St. Barth. Hosp. Reports, vol. HI, 1867. 



592 DISEASES OF CHILDREN. 

Many have held that dentition is the exciting cause of the 
laryngeal spasm in these cases, and no doubt the disease 
occurs about the time the teeth are commencing to make 
their appearance. All the thirty cases alluded to were under 
two years of age ; and most of them were under a year, 
from the eighth to the eleventh month being the favorite 
period. One other point must be alluded to — viz., that the 
disease is much more prevalent in the first than in the second 
six months of the year. For this observation we are again 
indebted to Gee.* Of sixty-three cases spread over three 
years, fifty-eight occurred from January to the end of June, 
and only five from July to December. Gee very reasonably 
supposes that inasmuch as teething and gastro-intestinal 
complaints, which are well-known producers of convulsions, 
are prevalent all the year round, the weather must in this 
instance be at fault. But not directly so. Gee attributes 
the disease to a nervous erethism begotten by close confine- 
ment to ill-ventilated rooms ; and this idea is well worthy of 
consideration. 

Infantile Spasm. — There is a class of cases met with in 
the out-patient room in no inconsiderable numbers, in which 
there is laryngismus of a mild type, but so persistent as to 
make it clear that some local laryngeal fault exists. Such 
children may show no evidence of rickets — no tendency to 
convulsions — although, seeing that rickets is a disease so 
prevalent, it is not to be wondered at that slight evidences 
of it may exist in some of these cases. The respiration in 
these cases is more reedy than in most of the cases of direct 
or spontaneous, spasm, and it is more persistent, being even 
to some extent present during sleep. Nevertheless, it is 
distinctly aggravated, and to this extent spasmodic, under 
any excitement. The history of these cases is that whenever 

* " On Laryngismus" : St. Barth. Hosp. Reports, vol. XI, 1875. 



REFLEX SPASM. 593 

excited — on suddenly awakening from sleep, when they are 
suddenly taken from a warm to a cold atmosphere, when 
they cry, sometimes when their position is suddenly changed, 
or when from sitting up they are placed in bed — a croaking 
noise is made as if the child were going to choke. The 
author has long thought that these cases must result from 
the conformation of the upper part of the larynx in early 
infancy. Supposing that at this time of life the larynx is 
too yielding, and that when a rush of air was produced by 
means of deeper or more hurried breathing than usual, it 
could not pass fast enough. It seems probable, however, 
from an observation made by Dr. Lees, that it is not so 
much a yielding of the parts as a natural condition which 
exists in some cases. Lees made an inspection of one of 
these cases which had died from other causes, and he found 
that the epiglottis was excessively recurved in its vertical 
axis — as if it had been bent in half down the middle, and 
that thus the ary-epiglottic folds were brought almost into 
apposition, and a mere chink left between them. Now, more 
or less of this recurvation of the epiglottis is a common 
thing in infancy and early childhood, and one can quite 
believe that some such condition as this may explain some 
of the cases of laryngismus, which would otherwise be 
swept into the net of convulsive laryngismus on account of 
the coexistence of a very moderate rachitis. The history 
of so many of these cases is that they breathe quite natu- 
rally until they begin to breathe hurriedly ; but as soon as 
this happens, no matter what the cause, then there is dysp- 
noea and crowing. And more than this, these cases are 
very little, if at all, relieved by treatment, and the symptom 
gradually passes off as the child grows older. 

Reflex Spasm, due to excitement or w r orry of the medi- 
astinal branches of the vagus, is, without doubt, a real oc- 
currence; but it has, to some extent, got into bad odor from 



594 DISEASES OF CHILDREN. 

the fact that some authors have endeavored to make all 
laryngeal spasm, apart from actual laryngitis, due to this 
cause. Thus, we have the spasm of pertussis due to bron- 
chial gland enlargement, thymic asthma from engorgement 
of the thymus, and other conditions due to other forms of 
mediastinal trouble. This view does not appear to me to 
be tenable. Mediastinal affections have their sphere in the 
provocation of laryngeal spasm, but not to the exclusion of 
other causes. One sees laryngeal spasm associated with 
cheesy bronchial glands, with cheesy bronchial glands 
softening, with suppuration in the mediastinum from other 
causes, with fleshy swelling of the mediastinal glands from 
acute inflammation, and even with a swollen condition of 
the thymus. Something of the same kind, too, occasionally 
occurs in association with acute pericarditis and pleurisy. 
It is no argument against the potency of these conditions 
that they are not always, or even mostly, effective in pro- 
ducing the spasm. All convulsive affections are so largely 
due to individual proclivity, to disorderly nerve discharge, 
that no doubt a personal element is requisite as well as the 
local condition ; but that the local condition is sometimes 
associated with laryngeal spasm, distinguished by associated 
symptoms which allow of a correct diagnosis, there can be 
no doubt. 

Symptoms. — The classical laryngismus is thus described 
by West : " The child throws its head back, its face and lips 
become livid, or an ashy pallor surrounds the mouth, and 
slight convulsive movements pass over the muscles of the 
face. The chest is motionless, and suffocation seems im- 
pending. But in a few moments the spasm yields, expira- 
tion is effected, and the crowing inspiration succeeds." 
Others depict it in still more alarming terms. But a disease 
of this severity is not often encountered. A large number 
of infants, most of them nine or ten months old, are brought 



REFLEX SPASM. 595 

to the out-patient rooms of hospitals. Some are very 
rickety ; more are but moderately so ; and some are not 
evidently rachitic at all. Sometimes there is a history of 
convulsions of one kind or another. But the child is 
usually in moderate or good health; all that is supposed 
to ail it is that as soon as it is the least excited — no matter 
what the cause — a fit comes on, and it is unable to get its 
breath ; and this is followed by a long-drawn inspiratory 
crow, of a similar character to that of pertussis, only not 
being preceded by such violent paroxysmal emptying of 
the chest by cough — it is, of course, less violent, noisy, and 
prolonged. There may be a wheeze in its character which, 
as West says, is something between the whoop of pertussis 
and the stridor of true croup. 

The crow over, there is perhaps a fit of crying, and the 
child returns quickly to its natural playful habit,, or else it 
remains fretful and out of sorts, with a continuance of 
carpo-pedal contractions, perhaps until there is a general 
convulsion or the attack slowly passes off. 

The spasm due to an infantile conformation is not, by any 
means, easy to distinguish clinically ; but the cause being 
persistent, the dyspncea will be more or less continuous, and 
slight inspiratory crowing will often occur two or three 
times during one inspiration. The inspirations may be of 
a more reedy or croaking character, and the crow is less 
associated with rickets — less of a convulsive affection — the 
child can hardly be said to be much, if at all, distressed by 
it — and it is less amenable to treatment. 

Reflex spasm is sometimes, one hardly dare say gen- 
erally, associated with more or less persistent wheezing, as 
if from general bronchitis. Thus, such cases are liable to 
be mistaken for spasmodic asthma. Asthma may occur, and 
very severely in children ; but the possible existence of 
some enlargement of the bronchial glands should always 



596 DISEASES OF CHILDREN. 

be in mind in such cases. Cough is another symptom of 
great value ; there may be a persistent laryngeal tone about 
it which is peculiar, and it may be paroxysmal, and so 
make the parent think the child must have whooping- 
cough. The likeness to pertussis is sometimes further 
increased by the occurrence of vomiting after the cough. 
Hoarseness is sometimes present. These features should 
be remembered after severe and prolonged attacks of per- 
tussis, and the attention turned to the possibility of the 
existence of some bronchial gland enlargement. 

Prognosis. — Most writers allude to a considerable risk 
which is supposed, by some, to attach to laryngismus, but it 
is clear that no definite opinion can be formed upon this 
point by using so vague a term. If laryngismus be due to 
a variety of causes, some may be dangerous, others not. 
This is how the case stands — a spasm of the glottis due 
to convulsions will necessarily be dangerous, because all 
convulsions in young children are attended with risk of 
sudden death ; and, in the same way, the reflex spasm, due 
to enlargement of the bronchial glands, or excitement of 
the peripheral branches of the nerves in the mediastinum, 
are dangerous, because the cause is a more or less persistent 
and usually an organic one; but the other forms are, at any 
rate, less dangerous. To that form of spasm which is due 
to infantile narrowing of the glottic aperture, hardly any 
danger attaches, and little more to the catarrhal spasm, 
although this disease is more closely allied to, or rather 
more liable to run into, true laryngitis and croup than is 
usually taught. It is, in fact, the milder form of laryngitis, 
which at the other end of the scale shows as croup — the 
distinction between the two extremes of the scale being the 
somewhat arbitrary one of quick recovery in the one case 
and not in the other. 

Treatment. — Catarrhal spasm has already been dealt with. 



TREATMENT OF LARYNGISMUS. 597 

For infantile spasm but little can be done, save, perhaps, to 
give tonic medicines, and await the growth of the child and 
the fuller development of the larynx. 

The direct spasm, associated as it is with rickets, den- 
tition, and general convulsions, must be watched and treated 
carefully. If there be any tendency to general convulsions, 
as indicated by carpo-pedal contraction, etc., the bowels 
should be freely opened by a couple of grains of calomel, 
or fluid extract of senna, cathartic acid, jalapine, cascara 
sagrada, or what not. The first named is as good, or per- 
haps better than any. After the bowels have acted well, 
bromide of potassium, or sodium, or ammonium, in three 
to five grain doses, may be given, with some syrup of Tolu 
and aqua anethi, three times a day. The bromide may be 
combined with half a drachm of the syrup of chloral, and 
subsequently, when the immediate tendency to convulsion 
has passed away, the syrup of the lacto-phosphate of lime 
and iron, or Parrish's food, or steel wine and cod-liver oil, 
should be given regularly for some time. The greatest 
attention must be paid to the ventilation of the rooms 
inhabited by these children. Rachitic laryngismus requires 
no close confinement to hot and stuffy rooms, but plenty of 
fresh air, and the body is to be sponged with cold water 
regularly every morning. 

In the reflex spasm, all such things as will tend to reduce 
enlargement of glands must be adopted ; these are a pro- 
longed sojourn at the seaside; the inhalation of iodine or 
chloride of ammonium ; chloride of calcium in doses of four 
or five grains three times a day ; of hypophosphite of sodium 
in ten- or twenty-grain doses (Sturges) ; of arsenic ; iodide 
of iron, and cod-liver oil, and possibly some local applica- 
tions applied between the scapulae over the fourth and fifth 
dorsal vertebrae. 



59§ DISEASES OF CHILDREN. 

3. Laryngitis in children may be classified thus : — 

Acute /Simple. 

I Membranous. 
Chronic (usually syphilitic). 

Acute non-membranous laryngitis is by no means uncom- 
mon. It occurs with, or after, measles, whooping-cough, 
pneumonia, scarlatina, and diphtheria; and also, among 
the lower classes at any rate, without any known cause, 
and it must be supposed, therefore, from simple expo- 
sure. The author has notes of nineteen such cases, seven 
of which, being urgently ill, were admitted to the hospital, 
under the care of his colleagues, Dr. Taylor and Dr. Bax- 
ter. They all got well without exception — most of them 
with the simple treatment of a steam tent. On looking 
over the admission book at the Evelina Hospital, from 
1874 to 1880, the author found that about forty-five cases 
of laryngitis were admitted, twelve being called croup and 
diphtheria. To these he has added his own cases. The 
age which is most liable to the disease comes out with re- 
markable precision as from one to four years : — 

Under 



Under 6 



Of a series of sixty-one cases, thirty-six were girls, twenty- 
five boys. 

The following case is a fairly typical one : A girl, aged 
four years, had measles three weeks before she came to the 
hospital. Her cough had continued ever since, but she was 
not noticed to breathe badly until four days previously. 
The breathing had since then rapidly become more difficult. 
The child was livid-looking, with a noisy inspiration and 
expiration, and at the least disturbance the dyspnoea and 



I 


2 


3 


4" 


5 





14 


10 


17 


5 


6 


7 


8 


9 


10 


1 


4 


3 





3 



LARYNGITIS. 599 

the retraction of the thoracic walls was considerable. The 
tongue was furred; the temp. 101.5 ; the pulse very quick 
and irregular ; no lymph could be seen on the fauces. She 
was admitted under Dr. Baxter, and placed in a tent and 
the atmosphere well steamed, and she quickly improved. 
Many similar cases could be given. • 

In the one or two cases that the author has been able to 
examine laryngoscopically, the epiglottis has been, perhaps, 
a little swollen, and the ary-epiglottic folds also, but the 
visible changes were not great. There is some difference 
of opinion as to the feasibility of using the laryngoscope in 
children. Some think the practice quite possible with 
patience, but it is doubtful whether laryngoscopy can be 
often available before the age of eight or ten years. 

The editor agrees with Steiner that simple laryngitis and 
pseudo-croup are but modifications of the same disease. In 
both the anatomical lesion is catarrhal in nature, in the 
former, however, the whole mucous membrane of the larynx 
is affected, in the latter chiefly that of the rima glottidis, the 
epiglottis and the ligamenta ary-epiglottica. 

It is also true that in severe cases of laryngitis, spasmodic 
attacks of difficult breathing or false croup are very apt to 
occur. This we have but recently seen in a case of acute 
laryngitis complicating rubeola. 

An attack may begin suddenly — usually at night — or 
may be preceded for a day or more by sneezing, running at 
the nose and huskiness of the voice or cry. When fully 
developed the voice is hoarse and rasping; there is dry 
cough of a peculiar brazen tone, a sensation of tickling in 
the throat and hurried, somewhat difficult breathing. These 
symptoms are worse or only present at night, when, too, 
there may be moderate fever. They last for three or four 
days ; when the cough becomes loose and recovery is 
rapid. 



600 DISEASES OF CHILDREN. 

In severe cases the voice is more brazen, and occasionally 
temporarily lost. The cOugh is harassing, paroxysmal and 
painful, the difficulty in respiration is more apparent and 
the movements are accelerated, and there is considerable 
pyrexia with the usual frequent pulse, dry skin and increased 
thirst. It is in these that well developed paroxysms of 
pseudo-croup arise. The spasm occurs at night and wakes 
the patient in a fright from his sleep. The face, head and 
neck first flush deeply, then become livid, the eyes are 
staring and the breathing labored and stridulous as if suffo- 
cation impended. The voice and cough are very hoarse or 
their sounds may be almost extinguished during the height 
of the seizure, but soon return after it is over. The pulse is 
frequent, the skin hot and there is great restlessness and 
anxiety. These paroxysms last from half an hour to an 
hour, and when the first occurs in the early part of the 
night it is apt to be followed by another, and unless meas- 
ures of prevention be used a repetition may take place on 
the next and even on the third night. The first is usually 
the most severe. Such severe attacks last somewhat longer 
than the milder ones, but the symptoms still show a tendency 
to remission or even intermission, being much lessened or 
disappearing during the morning or early afternoon. 

Diagnosis. — This seems to be very aptly expressed by 
the old proverb, " the proof of the pudding is in the eat- 
ing." A child comes with symptoms such as narrated, and 
it is generally impossible to say offhand whether it has 
membranous or simple laryngitis. If no membrane can be 
seen on the fauces, and there is no local inflammation, no 
enlargement or induration of the glands of the neck, but 
little fever, and no albumen in the urine, a fair hope may 
be indulged that the laryngitis is simple. No more can be 
said at first; the case must be allowed to unfold itself. 
But to show how impossible is a diagnosis sometimes, the 



LARYNGITIS. 6oi 

student may be reminded that many a case thought to be 
membranous has speedily recovered under a treatment of 
simple warmth and moisture; that many another case, 
perhaps made light of at its commencement, has slowly 
matured into a fatal membranous laryngitis. 

Prognosis. — All cases of laryngeal obstruction require a 
cautious forecast, for reasons just given, but no reliable 
opinion can be formed until the patient has been seen in 
bed, and after some hours of restriction to a regulated 
atmosphere of warmth and moisture. All such cases are 
naturally attended with risk so long as the breathing re- 
mains stridulous. But the dread symptoms will often 
quickly subside when the child is placed in a tent and the 
air steamed by the bronchitis-kettle. 

Treatment. — Of the first importance is a small tent not 
far from the fire, and from which a steam-kettle can be 
directed towards the patient. The child must not, however, 
be kept too hot — a temperature of 65 ° is not to be exceeded. 
Somewhere between this and 60 ° will be proper. " In warm 
weather, all that will be necessary will be a tent and the 
steam produced by means of a spirit-lamp placed under the 
kettle by the side of the foot of the cot. It is a good plan 
to medicate the vapor by some compound tincture of 
benzoin ; and, when there are suspicions of membranous 
inflammation, the mixture of creasote and carbolic acid, 
already recommended, is good 

If the case be a severe one, it is well to give an emetic, 
and simple powdered ipecacuanha root is at once harmless 
and effective ; five grains is usually sufficient ; a teaspoon- 
ful of the wine or syrup may be given if it be preferred, 
and the dose is to be repeated if not successful within half 
an hour. Considerable relief to the breathing is often pro- 
cured by this means; and, by a judicious repetition of the 
emetic as the breathing becomes embarrassed, the pressing 



602 DISEASES OF CHILDREN. 

symptoms are soon quite relieved or kept at bay. In the 
meantime, however, it is well to give small doses of antimo- 
nial wine, five minims every two or three hours, and to act 
upon the bowels with a little hyd. c. cret, or calomel In 
very severe cases, many recommend that four or six leeches 
be applied to the top of the sternum, and that a blister 
should be applied to the throat. Neither of these remedies 
can be regarded with favor. Emetics seem to be less 
dangerous and more reliable. Ice-cold compresses may be 
applied to the throat, and should all these means fail and 
there be a risk of suffocation — as happens in the worst cases 
— intubation or tracheotomy must be performed. Upon 
this head, however, it is worth saying that the student is 
often too urgent as regards operation. A child breathing 
stridulously no doubt requires most careful watching, but 
does not necessarily require an immediate operation. The 
larger number of cases of laryngitis, even with symptoms 
of some severity, are amenable to medical treatment, and 
therefore ' delay is always advisable until it be seen what 
effect the remedies may have upon the disease. Should an 
operation be resorted to, success will, in a large measure, 
depend upon the strict practice of the principles already 
advocated under the head of tracheotomy for diphtheria. 

Acute membranous laryngitis will not need much consider- 
ation here, as it would be only to repeat what has already 
been said under the head of diphtheria. There are many who 
hold that all membranous laryngitis is diphtheritic; others, 
who are equally dogmatic, that it is sometimes so, and some- 
times due to simple inflammation. And in this regard it is 
no doubt to some extent apposite that scalds of the throat, 
which are not very uncommon, seem liable to produce a 
membranous form of inflammation. But there are objec- 
tions to cases of this kind, because the local irritant acts by 
producing physical changes in the mucous membrane, some- 



LARYNGITIS. 603 

times even to the boiling of the surface and the detachment 
of a slough. But there are extreme difficulties surrounding 
the subject on all hands. The diphtheritic poison is one 
which appears to originate under a variety of circumstances, 
the absence of which is seldom possible to prove ; there are 
many cases of croup in which the existence of membrane is 
uncertain, yet they make part of the case in favor of an in- 
flammatory membranous disease when it is quite possible all 
the time that they maybe cases of simple laryngitis. The're 
is equally no doubt that many cases called croup at first, 
have proved to be diphtheritic by the fact that they have 
carried contagion ; and diphtheritic membrane may unques- 
tionably be confined to the larynx. The only ground upon 
which a distinction can be really maintained is that of clini- 
cal symptoms. If in a long course of years a large number 
of most experienced men say that membranous laryngitis is 
sometimes attended with high inflammatory fever — at others 
with low fever, requiring the brisk administration of the 
strongest nutriment at frequent intervals and plenty of 
stimulant, we should be careful how we neglect such state- 
ments. Many different conditions will produce a pneumo- 
nia, yet the pathological changes will be indistinguishable 
in one and the other. And so with membranous laryngitis. 
A similarity of local change is no conclusive argument in 
favor of a common cause, and if it can be established that 
at the bedside there are two groups of cases, the one with 
one set of symptoms and requiring antiphlogistic remedies, 
the other with another set and requiring other remedies of 
an opposite tendency, one would be inclined to trust to the 
symptoms as the best indication of the reality of the differ- 
ence. The only doubt is whether in diphtheritic laryngitis 
the symptoms are, as is maintained, markedly those of an 
asthenic or prostrating disease, as they certainly are in 
some of the worst cases of its tonsillar variety. 



604 DISEASES OF CHILDREN. 

Chronic laryngitis is more often of syphilitic origin than 
due to other causes — sometimes it is a remnant of former 
membranous laryngitis. Various diseases are met with 
from simple hoarseness to considerable inspiratory stridor. 

A child of eight or nine months old was recently under 
the author's care, who has had snuffles, rash, and ulcerating 
condylomata of the anus, and who was completely aphonic; 
it cried with a hoarse whisper, and had at one time 
some dyspnoea. This subsided under mercurial treatment, 
but the loss of voice remained, and no doubt there had 
been considerable laryngeal disease. Another case, of a 
girl of four, the author watched for a long time ; she was 
hoarse and breathed badly, and had a sunken nose. She 
gradually got worse, and tracheotomy became necessary. 
She also improved under mercurials and iodides, but the 
hoarseness continued, and she was ultimately lost sight of. 
Notes of several other cases could be given which have been 
improved or cured by mercurials 'or iodides in the hospital or 
as out-patients. Two exceptional cases must be mentioned. 
One a male infant, aged four months, was admitted to the 
Evelina Hospital. It was one of six children. The mother 
had had three miscarriages. The child had had a sore 
mouth and snuffles for a month. It was pale and emaciated, 
with purulent ozaena, snuffles, ulceration of the tongue and 
mouth, and it had a hissing aphonia with stridulous dysp- 
noea. Clean-punched deep sores were present about the 
anus and scrotum, and there were large brown discolora- 
tions in various places. The dyspnoea was very great, but 
the child was so emaciated and so young that no chance 
was offered of relief by opening the trachea, and it was 
therefore treated by mercurials alone. It died a short time 
after its admission, and at the autopsy a large vertical ulcer 
was found in the larynx at the base of the epiglottis, with 
perforation of the thyro-hyoid membrane. 



LARYNGITIS. 605 

The second case, a girl of four, was brought as an out- 
patient for noisy breathing, which had been getting worse 
for three months. She was a healthy-looking child, but 
breathed with a constant slight stridor which increased when 
she coughed or exerted herself. Her voice was but little 
altered, its pitch being slightly raised without loss of tone. 
There was a distinct elastic fullness of a peculiarly soft char- 
acter over the thyroid body, but no distinct enlargement of 
the body itself. The carotids were displaced outward, and 
there was bulging of the posterior wall of the pharynx. 
She was under view for about three months, and Mr. Clem- 
ent Lucas, who saw her with me, inclined to the view that 
retro-pharyngeal abscess existed with an enlarged thyroid. 
She was subsequently admitted under Dr. Taylor, and her 
breathing becoming worse, tracheotomy was performed, 
and she died not long after. The autopsy showed a large 
fatty tumor extending from the base of the skull down 
behind the pharynx.* With this case in view it may also 
be mentioned that an enlarged thyroid sometimes causes 
dyspnoea from pressing on the trachea, and that occasionally 
also the pressure of enlarged and caseous glands may do 
the same. 

Diagnosis. — This must be attempted rather by bearing in 
mind what are the possibilities, and by excluding those 
affections which in the particular case are not present. 
The symptoms of chronic laryngitis may be produced by 
syphilitic inflammation of the larynx, by warty growths in 
the larynx, by chronic thickening resulting from a bygone 
croup, or by extension of the disease from the mucous 
membrane around. It may also be simulated by disease 
outside, such as a retro-pharyngeal abscess or a new growth 

* This case has been published by Dr. Taylor in the " Trans. Path. Soc." 
1876-7. 

51 



606 DISEASES OF CHILDREN. 

of any kind. But in this class of cases there is usually 
marked dysphagia, and there are likely to be peculiarities 
in the case suggesting that it is not a simple one of laryn- 
gitis. As regards the cases of pressure upon the trachea to 
which allusion has been made, Gerhardt has stated that 
immobility of the vocal cords during the respiratory act is 
a symptom ; this might possibly be of use when a laryngo- 
scopical examination can be made. 

Of other conditions than these which cause laryngeal 
dyspnoea, warty growths in the larynx and retro-pharyngeal 
abscess are perhaps the more important ; but oedema glot- 
tidis may be occasionally met with, though but rarely, from 
the extension of inflammation fromthe tonsils or the mucous 
membrane of the nose and pharynx. Perhaps more common 
than any is a certain amount of obstruction to the respi- 
ration from a general thickening and hypertrophy of the 
pharyngeal mucous membrane — a state of things which 
may exist. The mucous membrane under these circum- 
stances is spongy and warty-looking — sometimes thrown 
into rugae, and altogether considerably narrowing the faucial 
passage. In such cases it is puzzling to know whether one 
is dealing with this disease or with some retro-pharyngeal 
abscess, the complete examination of the throat in young 
children being a matter of so much difficulty. The pha- 
ryngeal conditions are described more in detail in their 
appropriate place, p. yS. 

Prognosis. — This will, of course, depend upon the origin 
of the disease. So far as the dyspnoea is concerned, these 
cases do remarkably well. But one must be rather cautious 
in expressing an opinion as to the return of the voice, as 
the aphonia appears to be a less remediable condition. 

Treatment. — If the dyspnoea is at all urgent, and probably 
in any case, it will be advisable to try what a moist atmo- 
sphere will do, and either iodides or mercurials should be 



WARTY-GROWTHS IN THE LARYNX. 60/ 

given internally. In very chronic cases, where the dyspnoea 
is considerable and intractable, it may be well to consider 
tracheotomy as a remedial measure. It certainly would 
seem that the continued action of a larynx reduced to a 
mere chink, although sufficient perhaps for the purposes of 
aeration — but not without discomfort — tends to perpetuate 
its own ill by keeping up spasm and augmenting the pro- 
ducts of inflammation. Tracheotomy puts the parts at rest, 
and therefore favors their return to a healthy state. More- 
over, although at no time would one counsel a resort to 
laryngotomy or tracheotomy until all other means of relief 
had been discussed or exhausted, yet treated secundum 
arte///, the operation is ^ess dangerous in such cases than 
those in which it is performed for diphtheria, croup, or 
acute inflammation about the respiratory passages. 

4. Warty-growths in the larynx are rare, and their 
diagnosis very difficult; in one case, a child of about two, 
though examined by the most expert of laryngoscopists, 
and after tracheotomy, no diagnosis was arrived at. In 
another, an older child of four, the growths were seen in 
the larynx by the laryngeal mirror after tracheotomy had 
been performed. Long-standing hoarseness and difficulty 
of breathing, unassociated with fever, and when syphilis or 
phthisis can be excluded, are very probably due to a new 
growth ; to say this is to give a very concise and practical 
summary of our means of diagnosis. Laryngeal warts 
always have a well-marked cauliflower-like aspect ; they are 
true warts or papillomata, and they grow from the surface 
of the true vocal cords, or from other parts of the larynx, 
usually below them. 

Treatment. — This must necessarily be a difficult matter. 
If the growths can be attacked from the mouth, they may 
be swabbed with chromic acid solution, or still better, per- 
haps, painted with some salicylic cream or salicylic acid in 



608 DISEASES OF CHILDREN. 

glycerine ; and occasionally it is possible to remove them 
from above by operation. Two or three such cases are on 
record in children of such tender age as from three to five 
years. But in most cases the persistence of symptoms of 
chronic laryngitis ultimately leads to tracheotomy, and it 
is only after the operation that the throat becomes tolerant 
enough to enable anything to be done by the mouth. Pos- 
sibly the warts may then be removed by this channel ; they 
are easily detached if they can be reached. In several cases 
now on record, however, the continuance of dyspnoea has 
led to the operation called thyrotomy ; the thyroid cartilage 
is slit up in the middle, the larynx opened, and the warts 
removed, some solution such as named being applied to the 
diseased surface afterwards, and the parts again carefully 
adjusted and secured by sutures. This was done three or 
four times in a case under the care of Mr. Davies-Colley, and 
with ultimate success, and the patient was still well eight 
years later, but he could only talk in a hoarse whisper. 

The operation of tracheotomy for these growths has been 
performed, according to Gerhardt, fourteen times — six suc- 
cessfully at the ages of fifteen, eleven, six, six, five and a half, 
and three and a half years ; the remainder unsuccessfully 
at the ages of eight, three, three, two and a half, two and 
one-third, and two ; and from these data the conclusion is 
drawn, which is probably a sound one, that the younger 
the child the greater the risk from operation. Thyrotomy 
has been performed in twenty-one cases, but the results do 
not appear to have been very successful if we take into 
account that some patients died, and that in many the 
growths recurred, necessitating, sometimes, a repetition of 
the operation. Nevertheless, it should be performed when 
other means have failed. 

5. Foreign bodies in the trachea, if not expelled by cough- 
ing, will require surgical treatment, and probably trache- 



FOREIGN BODIES IN THE TRACHEA. 609 

otomy. They produce more or less general bronchitis and 
paroxysmal attacks of urgent dyspnoea. The history of these 
paroxysms is no doubt that the body, usually a pea or some- 
thing round, is drawn into the trachea and plugs the bron- 
chus. There it remains for a time until the mucous secretion 
set up by its presence induces a more than usually violent 
fit of coughing. This dislodges the body and drives it 
into the upper part of the trachea, perhaps into the larynx 
below the cords, where the irritation provokes spasm. By- 
and-by the body falls down again into its former position and 
the spasm subsides, to be again renewed until expulsion of 
the body is procured or broncho-pneumonia is set up by the 
worry of its presence. But there is a further point to be 
insisted upon — viz., that if the foreign body becomes fixed 
in the bronchus, there will probably be no paroxysmal 
dyspnoea. It is not uncommon for fish-bones and other 
bodies to become fixed in one or other bronchus — usually 
the right — and there to set up a unilateral bronchitis, the 
cause of which may be puzzling and overlooked unless the 
possibility be borne in mind. Numerous cases are on record 
of pieces of bone, wheat-ears, etc., becoming impacted in the 
bronchus, and thus setting up a fatal pneumonia. Dr. Wilks 
has published a case in which an ear of grass worked its 
way down the bronchus to the surface of the lung, there set 
up an empyema, and was discharged by the opening made 
for the evacuation of the pus. 

Treatment. — Foreign bodies may be expelled by cough- 
ing, or by emesis. Their expulsion has sometimes been 
apparently favored by holding the patient up with his head 
downwards ; but tracheotomy is often necessary, and the 
prognosis in such cases is not favorable unless the body is 
quickly expelled. Mr. Durham has successfully performed 
thyrotomy in one case, a cherry-stone being impacted in the 
larynx. 



6lO DISEASES OF CHILDREN. 

Dr. H. R. Wharton, one of the surgeons to the Children's 
Hospital, Philadelphia, has recently reported three cases in 
which tracheotomy was successfully performed for the re- 
moval of foreign bodies from the trachea and larynx. 

The first case was a boy, aged seventeen months, a patient 
at the Children's Hospital. After the production of anaes- 
thesia, the trachea was exposed and laid open, when a forci- 
ble expiratory effort occurred and a small white bean was 
expelled from the wound. A small silver tracheotomy tube 
was inserted as a matter of precaution. The child did well 
after the operation. The tube was permanently removed 
on the fourth day and he was discharged, the wound having 
entirely healed, two days later. 

The second case, a boy, aged nineteen months, was ad- 
mitted to the hospital on May 3d, 1883. Four days before 
he accidentally inhaled a portion of a grain of gourd-seed 
corn, and was at once seized with violent coughing and 
dyspnoea. When admitted the symptoms were so urgent 
that immediate tracheotomy was deemed necessary. Dur- 
ing the operation, which was performed without anaesthesia, 
the respiratory movements ceased and artificial respiration 
had to be resorted to. This was kept up for some minutes 
and hopes of resuscitation had almost vanished, when sud- 
denly a voluntary respiration occurred bringing the foreign 
body into the wound, whence it was removed. Afterwards 
respiration was performed freely so long as the tracheal 
wound was kept open by retractors, but as soon as these 
were removed and the edges fell together dyspnoea came on ; 
consequently a small tracheotomy tube was inserted. The 
operation was followed by no unfavorable symptoms, the 
patient quickly recovered and was quite comfortable while 
wearing the tube, though the recurrence of dyspnoea ren- 
dered its removal for any length of time impossible until 
July 23d, eighty-one days after its insertion. 



FOREIGN BODIES IN THE TRACHEA. Oil 

Besides early age there are two other features of interest 
in this case, namely, the respiratory arrest after opening the 
trachea, and the delay experienced in removing the tube. 
The arrest depended upon a falling together of the edges of 
the tracheal wound during the inspiratory act. Whether 
this was due to the natural flexibility of the trachea in early 
life, or to the prolonged presence of the foreign body hav- 
ing resulted in general inflammatory softening, the reporter 
does not attempt to decide, though he is inclined to regard 
the softening as an important factor, since the first case, not- 
withstanding its youth, was uncomplicated by dyspncea after 
the removal of the foreign body. The permanent removal 
of the tracheotomy tube is sometimes a matter of great diffi- 
culty, although it can usually be ultimately accomplished 
if enough patience be exercised. The trouble arises both 
from the fact that the granulations arising in healing may 
act like a valve -leaflet during inspiration, and from the irri- 
tability and disorderly action of the glottis muscles so likely 
to follow the operation. 

In both of these cases the operation was performed by 
Professor John Ashhurst, Jr. 

The third case was a girl, aged seven years, also a patient 
at the Children's Hospital. On the night before admission 
she supposed she had swallowed a pin which she was hold- 
ing in her mouth, but was convinced to the contrary by a 
sudden attack of coughing and by pain referred to the upper 
part of the larynx. On examination the only symptoms 
were pain, a sensation of " sticking " in the region men- 
tioned, and cough ; by the finger the point of some sharp 
body could be felt beneath the skin a little to the right of 
the pomum adami. After etherization Dr. Wharton made 
an incision a little to the right of the median line of the 
neck, where the point of a pin was seen imbedded in the 
right ala of the thyroid cartilage; it was seized with forceps, 



6l2 DISEASES OF CHILDREN. 

drawn down until its head impinged upon the inner surface 
of the cartilage, 'and its complete removal accomplished by 
a trifling incision. Very little air escaped through the inci- 
sion, there were no unfavorable sequelae and the patient 
made a rapid and complete recovery. 

The reasons for selecting the external rather than the 
internal method of removal were the extreme difficulty of 
controlling the child, and the fear that a delay might be 
followed by some unfavorable change in the position of the 
foreign body. 

3. DISEASES OF THE LUNGS. 
1. Bronchitis is one of the commonest affections of 
childhood. It is usually a disease of the large and medium- 
sized tubes, but is very apt to spread from these to the 
smaller tubes, and to lead to broncho-pneumonia and to 
atelectasis. It is in respect of these diseases that its impor- 
tance chiefly lies. It is usually ascribed to the effects of 
chill, but, without denying this in any way, its cause is far 
more often intrinsic than extrinsic. There are many chil- 
dren who have an acute bronchitis, mostly of the larger 
tubes, when teeth are just coming through the gums; 
there are others, usually older children, whose irregularities 
in diet and in the gastro-intestinal secretions are revealed 
in the same way. The ascaris lumbricoides may provoke 
similar disturbances, and the symptoms possibly subside 
on the expulsion of the worms. Such cases are probably 
of neurotic origin, and are examples of reflex nervous dis- 
turbance, the worry at one end of a nerve being trans- 
mitted to some other station in communication with it. 
Then there are the specific poisons, such as that of measles, 
of pertussis, or of typhoid fever ; there are local peculiari- 
ties of action in the muscle of the bronchial tubes ; there 
are all the conditions of catarrh in the upper passages; 



BRONCHITIS. 613 

there are the series of tubercular conditions which, in any 
given case, must all be taken into consideration ; and last, 
but not least, there are the chronic conditions dependent 
upon atelectasis, which are ever ready to excite an acute 
catarrh. No doubt, besides all these, there are many other 
causes of which we know even less ; exposure of the skin 
to chills will interfere with its action, will disturb the balance 
of the circulation, and tend to throw undue stress upon all 
the viscera, the lungs among them. Atmospheric disturb- 
ances, electrical and other, abnormal constituents of the 
particulate dust, must also be of importance ; but it is of 
very little use discussing these things at length, for at best 
it could be but as the blind man offering to lead his fellow. 
In dealing with bronchitis, however, and all such affections 
as are supposed to be produced by chill, the student must 
interpret the cause in the widest sense, and think out care- 
fully for himself how much or how little it may mean. 

Symptoms. — The onset of acute bronchitis is usually sud- 
den, attended with high fever (102 or 103 ), rapid, labored 
respiration, dilating alae nasi, and usually with a good deal 
of perspiration. The tongue is thickly furred. There is a 
frequent, short, dry, and subsequently a moist, cough. On 
examining such a case, the chest will be rising very rapidly, 
the sternum plunging forward, probably the lower ribs at the 
same time becoming retracted inward, and the diaphragm 
moving forcibly downward, so as to round the abdomen 
into a ball-like shape at the end of inspiration. The more 
the impediment to the entrance of air into the lungs, the 
more will these symptoms be noticed, and the seventy of 
the case may in great measure, therefore, be judged in this 
way. In the worst cases the features are livid and the child 
very restless. On percussion, nothing will be made out with 
certainty, and on auscultation there will be bubbling and 
squeaking all over the chest. At the apices the inspiration 
52 



6 14 DISEASES OF CHILDREN. 

will be harsh and the expiratory murmur long and snoring, 
while the sounds at the bases are moister, and will be trans- 
mitted more strongly to the ear, should the disease be asso- 
ciated with broncho-pneumonia. 

As a rule, there is no expectoration, and the cough need 
not be a prominent feature. Sometimes it is frequent and 
distressing, and occasionally it comes on in paroxysms, and 
is attended with the passage into the mouth of muco-puru- 
lent material, not unlike that in pertussis, which should be re- 
moved by a pocket-handkerchief. At other times/although 
the respiration is very rapid, the cough indicates by its 
harshness that the upper parts of the air-passages are mostly 
affected. 

The disease is one of variable duration — seven or eight 
days may be given as perhaps an average. It is usually 
accompanied by anorexia and thirst, while the urine is 
stated by Meigs and Pepper to be frequently temporarily 
albuminous. 

But a large number of children who apply for treatment 
in the out-patient rooms of hospitals have a much milder 
attack than this. They are out of sorts, often rickety, and 
have cough with some slight pyrexia, and on auscultation 
some coarse and fine rales are heard in various parts of the 
chest. 

An equally important group of cases is related to the acute 
bronchitis which follows a persistent dilatation of the tubes 
and atelectasis. In these cases, again, the respiration is very 
rapid, shallow, and often labored ; the child is restless, blue, 
and bathed in perspiration, and there is a frequent short, 
moist cough. The temperature generally rises to 102 or 
so. The tongue is thickly furred. The auscultatory signs 
are much like those in the former case, but, supervening as 
the disease does upon collapse and bronchiectasis, there 
may be very little air entering the bases of the lungs, 



BROJsXHITIS. 615 

more or less dullness, and even signs of considerable con- 
solidation. 

Diagnosis. — Two difficulties may be noticed — one as re- 
gards the general symptoms. There are many children 
during the period of the first dentition who suffer from an 
acute febrile condition of sudden onset, and in which the 
respiration quickens in proportion to the fever. It is not 
difficult to mistake the appearances in such a case for those 
of bronchitis, but the auscultatory phenomena are not those 
of bronchitis, and after two or three days — perhaps before, 
perhaps on the eruption of a tooth, or on the administration 
of some aperient or diaphoretic — down drops the temper- 
ature, as suddenly as it rose, and the child is practically 
well. 

A more serious difficulty is to determine whether there 
is any actual consolidation of the lung. Very careful aus- 
cultation will be required to determine the point, and a 
careful weighing of the character of the mucous rales that 
are to be heard. And when the acute disease supervenes 
upon a chronic condition, the amount of dullness toward the 
bases from the preexisting collapse makes the question a 
difficult one to decide. Bronchitis, collapse, and broncho- 
pneumonia, are, however, so frequently associated that in 
one sense the importance of the question is minimized, and 
it is often decided rather upon the general symptoms than 
upon the physical signs, which may be hard to gauge with 
accuracy ; in another sense it is of more importance, deter- 
mining, as the existence of pneumonia often will, a fatal 
issue. Carmichael remarks on the diagnostic value of the 
temperature in these cases : " The record of acute bronchitis 
is usually pretty regular, whereas, that of pneumonia is often 
markedly remittent." Under special circumstances, also, the 
diagnosis becomes difficult. For instance, at the termina- 
tion of whooping-cough, the wasted condition of the child, 



6l6 DISEASES OF CHILDREN. 

and the excess of pulmonary impediment, may easily simu- 
late phthisis. The bronchitis of typhoid fever has already 
been alluded to as being occasionally so severe as to mask 
the essential disease. 

Prognosis. — This must depend upon the general symp- 
toms rather than upon the physical signs. Where the respi- 
ration is very rapid and labored, the dyspnoea increasing, 
the child blue and exhausted though restless, cool, and 
clammy, somnolent, and taking food badly, the prognosis 
must be grave. If, too, there be much inspiratory retrac- 
tion of the sides of the chest, or the sharp rales of broncho- 
pneumonia in addition, or if the child be very drowsy, or 
the Cheney-Stokes' type of respiration become at all pro- 
nounced, there is of necessity an added risk. All the same, 
the opinion should be a cautious one ; for, with careful 
treatment, the apparently worst cases may slowly pull 
round. 

Treatment — The child is placed in bed, and in a tent 
with a steam-kettle in the neighborhood to moisten the air. 
A little carbolic acid may be put into the vapor — one in 
eighty will be sufficient. A jacket of cotton-wool should 
be made to lightly envelop the chest. Many think highly 
of a mustard counter-irritant. The food should be easily 
assimilable, not necessarily milk or beef-tea only, but egg, 
custard, blanc-mange, jelly, sponge-cake, etc. 

For medicinal administration, some expectorant should 
be given — bicarbonate of potassium, nitrate of potassium, 
iodide of potassium or sodium and chloride of ammonium 
favor the liquefaction and discharge of the products. They 
may be given singly or combined, and some syrup of Tolu 
and aquae anethi added to make them palatable. If the 
prostration be great, carbonate of ammonium and ipecacu- 
anha wine make a useful combination. As the secretion 
from the bronchial tubes becomes more fluid an emetic may 



BRONCHITIS. 617 

sometimes be given to clear the tubes — a teaspoonful of the 
vin. ipecac, or five grains of the powdered root. Alcohol 
is often beneficial in severe bronchitis ; it is best adminis- 
tered as brandy or rectified spirit. Subsequently, a little 
syrup of squills, with the lacto-phosphate of lime and iron, 
may be given. The bowels should be kept gently open by 
aperients, as may be necessary ; and, in the later stages, 
quinine may be useful, as well as cod-liver oil and other 
general tonics and restoratives. 

Chronic Bronchitis is sometimes a result of an acute 
attack, or several such ; it sometimes remains after whoop- 
ing-cough ; sometimes it is the sequel of atelectasis ; and some- 
times all we can say is that it exists, but how it came about 
there is no evidence to show. Under any or all of these 
conditions the child is more or less blue, with short breath 
and a deep chest, flattened from side to side, with a promi- 
nent sternum ; the finger-ends are bulbous ; it moves about 
in a lethargic way, as if life were an exertion, and has a 
frequent short moist cough. Sometimes the chest is full 
of moist rales, both large and small ; sometimes there is 
little to be heard, except that the inspiratory murmur is 
clipped or shortened, and somewhat labored. A long 
expiratory murmur is not a very marked feature of bron- 
chitis in childhood. In the more advanced cases, the cya- 
nosis and clubbing of the fingers may be extreme ; the 
inspiratory recession of the lower and lateral parts of the 
thorax is very great. There may be evidence of distention 
of the right side of the heart, in the fullness of the veins 
and epigastric pulsation ; but the lungs, being emphyse- 
matous in front, do not often allow of the detection of any 
increase of the praecordial dullness on the right side. Even 
allowing that it occurs to the extent that is sometimes 
represented, Dr. Goodhart feels positive that dilatation of 
the right side of the heart displaces the impulse to the left 



6l8 ■ DISEASES OF CHILDREN. 

quite as often as it enlarges the praecordial area to the right. 
The copious expectoration of pus, and sometimes of offen- 
sive pus, has been said to occur in older children, and to be 
indicative of dilatation of the bronchial tubes, but this must 
be of very exceptional occurrence. 

Morbid Anatomy. — Such cases as these are apt, in the end, 
to be fatal by the repetition of the attacks. Each attack 
leaves the lung in a worse state than it was before, and the 
child's condition is one of gradual deterioration. The ap- 
pearances usually found are patches of solid collapsed lung 
in various parts, more particularly toward the base and 
round the lateral region of the thorax ; and the bronchial 
tubes are considerably dilated and full of thick pus. Thick- 
ening, roughening, and ulceration of the mucous membrane 
of the tubes have been described, but such conditions are 
rare. It seems to be much more remarkable how seldom 
there are any marked changes in the tubes commensurate 
with the extent of disease, if dilatation be excepted. The 
tubes are generally dark-colored and congested, but not 
swollen or roughened in any way. The dilatation of the 
tubes is seldom other than a uniform one ; saccular dilata- 
tions are quite uncommon. The lungs are usually moder- 
ately emphysematous along their anterior borders, at their 
edges elsewhere, and at their apices. In addition to the 
morbid appearances in the lungs, there will be found, more 
or less, those associated conditions of the viscera dependent 
upon the obstruction to the pulmonary circulation — viz., a 
large and probably dilated right heart, a nutmeg liver, and 
congested kidneys. 

Prognosis. — These cases usually go on for a long time. 
Their history is for the most part one of chronic ailment, 
with intercurrent attacks of more acute inflammation, in all 
of which they are very ill, and the issue for the time doubt- 
ful. In one of these attacks they may ultimately die. Such 



BRONCHITIS. 619 

cases, however, repay care ; for again and again they may 
pull through a serious attack, when apparently in an almost 
hopeless state, and one is justified in saying that, in many 
cases, something amounting to repair goes on. In young 
children, it is not incorrect to say that they may " grow 
out of it," for they greatly improve as their ribs stiffen. 
But there are other risks — one is of acute pleurisy, another 
of some ulceration of the lung ; both these come about by 
the medium of dilated bronchial tubes. The secretions 
collect in them, near the surface of the lung or elsewhere, 
and, decomposing, set up an acute pleurisy, or some destruc- 
tive broncho-pneumonia. 

Treatment. — This is much the same as for other more 
acute cases. They require always to be kept very warm, to 
be warmly clad, exposed as little as possible to the vicissi- 
tudes of climate, and in any acute attack to be kept in bed. 
Alkalies are useful in promoting expectoration, and some 
stimulating expectorant may be added to them. Four or 
five drops of sal volatile with a similar quantity of tincture 
of senega, and some bicarbonate of potassium with some 
syrup of Tolu, make an effective mixture at this time. In 
the later stage, when the expectoration is very copious, 
alum or gallic acid may be given : — 

R. Acid, gallic, gr. x 

Vini opii, lt\v 

Spt. vini gal., f^iss 

Aq. chloroform, q. s. ad (% iss. M. 

Sig. — Teaspoonful 3 times a day. 

R • Alum, 3 ij. 

Boil in a pint of milk and sweeten. 

Sig. — A tablespoonful frequently. 

R • Alum, 3 ss 

Vini ipecac, f^iss 

Syr. tolu, f^ ss 

Aquae, q. s. adf^iij. M. 

Sig. — 3 ij every 3 or 4 hours. 



620 DISEASES OF CHILDREN. 

Besides internal remedies, daily friction of the back and 
sides of the chest by soap liniment or simple oil seems 
sometimes to be of service. Later still, these cases usually 
do well upon mild ferruginous tonics. Quinine is also ad- 
vised at this stage, and there can be no objection to its 
administration in half-grain doses three times a day. Qui- 
nine is best administered in milk, but it may be given with 
syrup or liquorice, and the recommendation of Meigs and 
Pepper, to combine it with a little curacoa, is a good sug- 
gestion, if there be much repugnance to it in other ways. 
Maltine, cod liver oil, and such like remedies, are also often 
valuable in improving the general health of the child. 

2. Bronchiectasis. — It may be quite an open question 
whether this is to be considered a distinct disease ; the rea- 
son for devoting a separate paragraph to its consideration 
is that it has been taught that there are special symptoms 
disclosing its existence, and one would like, therefore, to in- 
dicate what these are. It would appear that it occurs mostly 
between five and nine years, twelve out of twenty cases being 
within that period. Bad pertussis frequently antedates it. 
From notes of twenty cases in which the author supposed 
this condition to be present, there is expectoration, some- 
times vomiting of large quantities of thick, purulent, possi- 
bly offensive pus. The chest is usually deformed, either 
pointed in front or flattened on one or other side, and there 
is often an irregularly distributed dullness perhaps at one 
apex, and on one side, or in patches in different parts of the 
lungs. The physical signs are those of bronchitis of the 
large tubes, with occasionally some sharp rales in various 
parts of the lungs. It is but seldom that anything sugges- 
tive of cavitation is heard, probably because these dilata- 
tions usually occur in the substance of the lung and are 
surrounded by vesicular pulmonary tissue. There is usually 
more or less cyanosis, clubbing of the fingers, and a gener- 



BRONCHIECTASIS. 62 1 

ally labored breathing and indolent habit. With the excep- 
tion, perhaps, of copious expectoration of pus, these symp- 
toms indicate not so much dilatation of the tubes as that con- 
dition of lung to which the dilated tubes owe their existence, 
and this may be sometimes a chronic bronchitis, sometimes 
extensive collapse, sometimes some old fibroid changes on 
one side or the other. Dr. Goodhart adds, as very note- 
worthy, that it is by no means uncommon for cases of re- 
puted bronchiectasis to give good evidence, upon careful 
examination, that they are instances of overlooked emphy- 
sema. It has been supposed by some that there is a special 
significance in fetor of the expectoration. This is doubtful. 
It is much more near the truth that when fetor of the bron- 
chial discharges exists there is generally some destructive 
disease of the lung or ulceration of the bronchial tubes. 

Morbid Anatomy. — The commonest form of dilatation is 
a uniform one. A section of the lung shows the tubes 
unduly large, and the scissors run along them with ease to 
the surface of the pleura. They generally contain more or 
less thick pus. Their lining membrane is red or livid ; 
thickening is not a noticeable feature, the surface may look 
slightly granular. This state of things is very usually asso- 
ciated with emphysema at the anterior and basal edges of the 
lungs, and also with some collapse. Saccular dilatation is 
rare. The tubes in these cases are thin rather than thick, 
and form sections of cysts on the cut surface of the lung. 
These occur in the substance of the lung rather than near 
the surface, and are often surrounded by a small nodule of 
consolidated lung. An exaggerated form of this disease is 
met with occasionally in which these cysts are very numer- 
ous and very large, the sections of the lower parts of the lobes 
being thickly studded with them. The lung-tissue inter- 
vening is at most only emphysematous and the pleura is 
usually adherent. Very little is known about this condi- 



622 DISEASES OF CHILDREN. 

tion ; it seems that it might possibly be of congenital origin, 
the physical signs have been so little pronounced, and the 
evidences of the disease so obscure. There is yet a third 
condition, in which usually one or other base of the lung is 
contracted and condensed, and the tubes are more or less 
widely dilated. The dilatation in these cases is neither uni- 
form as in the condition already described, nor saccular as 
in the other, yet on slitting them up along their course there 
is a good deal of irregular dilatation, and the cavities so ex- 
posed are puckered by the existence of transverse rugae. 
These also are found chiefly in the substance of the lung. 
This state of things is usually dependent upon some old 
pleurisy or chronic pneumonia. 

The prognosis and treatment are much the same as for 
chronic bronchitis. These children require to be kept in as 
pure an air as possible, in as equable a temperature as pos- 
sible, and, save when any acute attack threatens, in a dry 
atmosphere. If there is much accumulation of mucus in the 
tubes, an occasional emetic will relieve them, and for the 
rest they require tonics and fattening. 

3. Pneumonia. — It is usual *to describe this disease as 
lobar, fibrinous or croupous ; and lobular or catarrhal and 
broncho-pneumonia ; but, time-honored though such a 
description may be, it is liable to mislead the student. An 
acute pneumonia — which has the clinical features of the 
croupous pneumonia of adult life — is not uncommon in 
childhood; sudden onset; high fever; crisis; and sudden 
fall of temperature. But the difficulty is that the larger 
proportion of cases of pneumonia are not quite this, and 
yet they are lobar pneumonias as regards their physical 
signs. They run a less typical course, and while partaking 
in some respects of the nature of the one form of disease, 
in others they are more like the catarrhal form. Nor is 
the difficulty lessened by appealing to the facts of morbid 



PNEUMONIA. 623 

anatomy ; for acute pneumonia, be it clinically lobar or 
lobular, seems to present such appearances in every case, as 
make any distinction between the two forms, save one of 
degree, a very difficult matter. The author is not familiar 
with the red and gray hepatization which are described as 
occurring in childhood as in adults, when the disease is of 
the fibrinous form ; but the clinical data are sufficiently pre- 
cise to forbid all doubt that such a disease as acute fibrinous 
pneumonia has a very real existence. The student must 
bear in mind, however, that the lobar pneumonia of children 
is more often catarrhal than fibrinous, and that, therefore, 
the disease here described as such has a wider range than 
that usually given to it. The remarks which follow are, 
indeed, chiefly based upon the commoner form of the 
disease, and the morbid anatomy is described from the fatal 
cases resulting from this form. This catarrhal origin may 
explain the fact that the lobar pneumonia of children so 
often begins at fehe root of the lung, and spreads upward 
or downward ; here also may possibly be found an explana- 
tion for another fact — viz., that pneumonia at the apex of 
the lung is, as is usually supposed, a commoner disease in 
children than in adults. The pneumonia of adult life com- 
mences as a parenchymatous change at the base of the 
lung, and extends up the posterior part, reaching the apex 
and front last of all. But if the root be the more frequent 
seat of onset, it is clear that the apex and base are equally 
exposed to the risk of extension, and an apex pneumonia 
might be expected to be more common. Goodhart has 
analyzed all his cases with a view to giving some informa- 
tion upon some of these points, and one or two interesting 
facts are arrived at by this means. 

Out of 165 cases, forty-five were lobular pneumonia, 
with a mortality of twenty. Such a small number of cases 
of lobular pneumonia is, in part, accounted for by the fact 



624 DISEASES OF CHILDREN. 

that — being more common — less careful notes have been 
taken of such cases, and, in part, by many cases being in- 
cluded with those of bronchitis. One hundred and twenty 
were lobar; fifty-one of the left base, with fourteen deaths ; 
seventeen of the left apex, with two deaths ; thirty-four of 
the right base, with two deaths ; eighteen of the right apex, 
with seven deaths. Apex pneumonia appears, then, to 
occur twice to five cases where the disease is basal ; while 
disease at the right apex is the most fatal, and that at the left 
base next. Henoch gives seventy-four cases, two in which 
the disease attacked the entire right lung; two both lower 
lobes ; twenty-one the right upper lobe ; eighteen the right 
lower lobe ; four the left upper lobe ; and twenty-seven the 
left lower lobe. Barthez and Sanne give the following 
figures: Right apex, 170; left apex, 47; right base, 41; 
left base, 69 ; middle of lung, 49 ; the greater part of one 
lung, 32 cases; total, 408. As regards the mortality, the 
author's figures are, however, open to the exception that 
four-fifths were from out-patients. The mortality is, there- 
fore, probably higher than it need be. No mention has been 
made of double pneumonia, because in all these cases it 
was essentially one-sided ; but in several cases patches here 
and there were discovered from time to time in the course 
of the disease ; this agrees with the opinion of Dr. West 
that double pneumonias are not uncommon. There is some 
difficulty in being sure of the fact in the absence of an 
autopsy, for the sounds of consolidation are transmitted 
from side to side, particularly about the root, with great 
readiness ; and it is also quite common in the auscultation 
of the lungs of children suffering from pneumonia to meet 
with evidences of consolidation at one visit which have 
gone at the next, or within a short time, and which must 
indicate a still more ready interchange of collapse and 
expansion than has, possibly, hitherto been appreciated, 



PNEUMONIA. 625 

notwithstanding all that has been written on the subject. 
For this reason one hesitates to say that the disease attacks 
one side more frequently than the other, but it is usually 
stated that the disease of the right side predominates. 

Of the above cases, seventy-seven were girls and fifty 
boys. This is not in accord with general experience, but, 
as is well known, different sets of statistics are liable to give 
contradictory results. It appears pretty certain that, taking 
a large number of cases, pneumonia occurs more often in 
boys than in girls ; but these numbers are given for what 
they are worth. Nor can more than partial agreement be 
held with others as regards the age of patients suffering 
from lobar pneumonia. No doubt nearly all cases occur 
under five years (eighty-two out of ninety-three) ; fifty-one 
cases were under two, and thirty-one between two and five. 
Such discrepancies as exist may be explained in great 
measure, if instead of taking an anatomical basis of classifi- 
cation, we take the clinical one — the younger the child, the 
more is the disease associated with bronchitic symptoms, in 
which the disease may often originate ; the older the child, 
the more likely is the disease to have a sudden onset, per- 
haps by convulsions, and all the signs of bronchitis to be 
absent. 

Morbid Anatomy. — The lobar pneumonia of childhood, as 
seen in the post-mortem room, differs from that of the adult 
in wanting the distention or solidity that is found in adults, 
and also the granular or dull rough surface which is so 
characteristic. As in adult life, it is often associated with 
pleurisy. The child's lung is smaller, denser, darker colored 
than natural, of a bluish, violet, or leaden tint, and the cut 
surface is comparatively smooth. It is often very finely 
sanded, and may look vesicular, or almost gelatinous When 
the disease has progressed some few days, the surface 
thus described is mapped out with gray lines of thickened 



626 DISEASES OF CHILDREN. 

interlobular septa, and is generally studded over with 
circinate patches of granular yellow or yellow-red color. 
These are the terminal bronchi with the pulmonary vesi- 
cles around them full of inflammatory material, on its way 
toward gray or fatty changes. The intervening parts are solid, 
dark-colored, and hardly granular. They are more solid 
than in simple collapse ; less so, at any rate less bulky, than 
in the lung of acute croupous pneumonia. This is the con- 
dition which has no doubt given rise to so much questioning 
and discussion — some calling it collapse, others pneumonia. 
Matters will not be much bettered, perhaps, by saying that 
it is neither one nor the other ; but, none the less, such a 
statement is strictly true. In childhood the respiratory 
movements and the circulatory conditions are not exactly 
the same as in adults. As before said, if we listen over a 
child's chest we frequently hear that now one part, now 
another, is moving more fully, depending upon a less uni- 
formly equable expansion of the chest; and with dissimilar 
conditions come dissimilar morbid changes. The common 
form of pneumonia in early life is due to a complex series 
of changes ; in part, and no doubt a prominent part, due to 
collapse ; in part to catarrhal changes in the tubes and air- 
vesicles ; in part to blood-stasis simply ; in part to swelling 
and thickening of the connective tissues surrounding the 
smaller bronchi and the septa of the lung. The last- 
mentioned conditions are very prominent features of the 
pneumonia of childhood, while the exudation of fibrin is of 
very limited occurrence. It is by no means certain, also, 
whether some process of adhesion may not go on in the 
walls of the inflamed air-vesicles. If not, they become 
much thickened and fibroid-looking, and in parts of such 
lungs the vesicular structure may be quite obliterated, and 
the observer appear to be looking at an unbroken field of 
fibro-nucleated tissue. It is most difficult in some cases to 



PNEUMONIA. 627 

say what is the exact nature of the changes histologically ; 
but this is certain, that appearances quite unlike those of 
the acute pneumonia of adult life often present themselves. 
Neither are such changes comparable to those met with 
after compression by fluid. The peculiarities in the ana- 
tomical appearances have been described by several writers. 
Rilliet and Barthez ascribe them, in part, to the interstitial 
exudation alluded to; others to a lessened amount of 
fibrinous exudation. The author supposes that both these 
departures from the adult type are of importance. The 
absence of fibrinous exudation may, however, be particu- 
larly insisted upon, because, if such be the case, it will be 
apparent how difficult it must sometimes be to distinguish 
between pneumonia and collapse of the lung. 

The nature of the later stages of a lobar pneumonia in 
children is also by no means free from obscurity ; but from 
what is seen in lobular pneumonia and from an occasional 
case of fibrinous pneumonia, it has been more surmised than 
proved that there is some such change as that denominated 
gray hepatization, and through which resolution comes 
about. Nevertheless, remember that children hardly expec- 
torate at all ; nor are they in many cases troubled much 
with mucus in the tubes. The breathing has been said to 
be easy in these cases, in contradistinction to the labor of 
bronchitis ; therefore, probably in many cases some process 
of liquefaction and absorption occurs; in fact, that which is 
occasional in the adult is common in childhood. In the 
more chronic cases no doubt there is a tendency to the 
formation of patches of cheesy pneumonia, or to a* condi- 
tion, presently to be described, in which a considerable 
part of one lobe may become converted into a solid cheesy 
mass. 

Fibrinous pneumonia being but seldom seen in children 
in the post-mortem room, the well-known characters of the 



628 DISEASES OF CHILDREN. 

disease in the adult render its description unnecessary. 
The following is the most recent case seen by Dr. Good- 
hart : Boy, aet. 2]/ 2 years, admitted into the Evelina Hos- 
pital, and dying within a few hours of admission. At the 
autopsy there was well-marked gray hepatization of the 
upper lobe, commencing apparently in the lower part of it 
and spreading upward, but the actual apex was free. 

It appeared to be an ordinary case of acute croupous 
pneumonia, clinically and otherwise, but a large mass of 
caseous glands occupied the mediastinum at the bifurcation 
of the trachea. 

The morbid appearances of lobular pneumonia differ 
from the lobar form in distribution, but not much other- 
wise. A section of a lung thus diseased shows an uneven 
surface, from the existence of eminences and depressions. 
According to the stage arrived at, so will the eminences be 
either simply dark-colored from congestion, and their rela- 
tions to the smaller bronchi perhaps not very distinct ; or 
else actually solid, with a central dilated bronchial tube 
containing pus. In the latter case the eminences will either 
be of a dark livid color, almost translucent near the central 
bronchus, with no well-defined margin, or yellow or fawn- 
colored from the degenerative changes in the inflammatory 
products. In this way are produced clusters of nodules, 
the cut section being often finely granular ; and these may 
run more or less together, solidifying the whole lobe, or 
part of it, and producing a nodular solidification, which 
gives to the diseased part a somewhat peculiar feeling 
when grasped" between the finger and the thumb. Histo- 
logically, the smaller bronchi are often very much thickened 
by a crowded cell-growth in their submucous tissues, and 
the air-vesicles around such affected tubes are full of 
inflammatory products, but accompanying these changes, 
and in proportion to the diffusion of the centres of inflam- 



PNEUMONIA. 629 

mation, and to the duration of the disease, is a very similar 
state of things to that described under the head of lobar 
pneumonia. The smaller bronchi are often dilated. 

Hillier describes lobular pneumonia as disseminated or 
generalized, and when the latter, closely resembling the 
lobar form. He also alludes to a description by Ziemssen 
of chronic cases of this variety taking origin in collapsed 
parts, a change which sometimes involves a whole lobe. 
The appearances of this disease seem to be identical with 
what has been here described as the common form of lobar 
pneumonia in children. 

Causes. — Little is known of the cause of fibrinous pneu- 
monia. It generally appears to be spontaneous, but its 
etiology is involved in as much doubt as is the like disease 
in adults. Some consider it due to exposure ; others to 
atmospheric disturbances ; others to septic conditions, etc. 
All, however, seem to agree that a child attacked once may 
be so several times. It is more common in the strong than 
in the weakly, and in the winter and spring than in the 
summer months. 

The catarrhal form of lobar pneumonia and the dissemi- 
nated lobular pneumonia more often follow measles, whoop- 
ing-cough, and other acute specific diseases, and are the 
termination of not a few cases of atelectasis and chronic 
bronchitis. 

Symptoms. — We must now more sharply distinguish 
between the fibrinous and the catarrhal forms of the disease. 
Acute fibrinous pneumonia is, as in adults, a disease of sud- 
den onset, but this may be masked in young children by 
diarrhcea and symptoms of gastric enteritis. There may be 
rigors or convulsions, headache, vomiting, muscular pain, 
pain in the side, and high fever (103 to 105 °). Dr. Emmett 
Holt states that repeated attacks of vomiting occurred in 
half his cases, and that convulsion was the next most com- 
53 



63O DISEASES OF CHILDREN. 

mon symptom of onset. It is a disease of a few days only, 
ending in a crisis, but it may last any time, from three or 
four days to seven, eight, or nine. It is usually associated 
with pleurisy, and this to some extent masks the disease, 
and gives its symptoms a special color. The pain may be 
very acute for a day or two, and the child's features, par- 
ticularly if it be very young, may*become pinched. The 
cough is stifled, or with it there comes a cry, or sometimes 
a shriek. As between bronchitis and pneumonia, Meigs 
and Pepper allude to a distinction which is not unservice- 
able, that the child with pneumonia breathes easily, though 
very rapidly, while the bronchitic gets his breath with labor. 
Of course, with much pleurisy this is modified, and the 
child with acute pleuro-pneumonia sits up in bed giving 
vent by turns to short grunts and a harsh, dry, short cough. 
The child's face is flushed, its skin hot and dry, the lips, 
perhaps, covered with herpes. Some cases are ushered in 
with violent cerebral symptoms, and have been described 
by Rilliet and Barthez as a distinct variety, " cerebral pneu- 
monia." In frequently recurring convulsions, and in head- 
ache, vomiting, delirium, and drowsiness, these cases may 
resemble, and be mistaken for, meningitis. Moreover, they 
are usually severe, and Hillier and others consider them 
more likely to occur with pneumonia at the apex than else- 
where, and this has certainly been the experience at the 
Evelina Hospital. It may be worth while to point out, in 
reference to this observation, that some have thought that 
apex pneumonia in adult life is not only severe, but liable 
to own a septic origin. Possibly, also, the fact already 
insisted upon, that a pneumonia of the apex is often a pneu- 
monia of the root of the lung, may also have its meaning 
in this respect. 

The disproportion between respiration and pulse — nomi- 
nally three and a half or four to one — is usually well 



PNEUMONIA. 63I 

marked, the former rising to sixty or seventy per minute. 
The alae nasi dilate with inspiration until the severity of the 
disease lessens. The temperature generally falls suddenly 
from 103 or 104 to normal, or below it, and may rise 
again slightly at night for a fortnight before it finally rights 
itself; and here it may be mentioned that Dr. Newnham, 
formerly resident medical officer at the Evelina Hospital, 
states that it was no uncommon thing for him to receive 
a summons from a nurse to come at once to such a case, 
because the temperature had fallen, quite suddenly, perhaps 
from 103 or 104 to below 98 , and the nurse has feared 
something was going wrong with the child. If, after the 
crisis, the temperature should again rise, particularly at 
night, the formation of fluid, and perhaps pus, in the pleura, 
or some fresh mischief in the lung, may be suspected. These 
acute forms of inflammation of the lung are not at all un- 
commonly succeeded by empyema. Associated with the 
crisis there is usually copious perspiration. Recovery after 
the crisis is often astonishingly rapid ; the solidification, as 
judged by the physical signs, will sometimes disappear 
within a day or two, nor is it necessarily accompanied by 
much evidence of softening in the way of mucous rales. 
Steiner makes a note that in several cases he has found 
complete absorption to go on without the occurrence of 
any moist rales. The tongue is naturally often thickly 
furred ; vomiting may be obstinate for the first day or two ; 
the bowels are confined ; the urine scanty, and its chlorides 
absent. The temperature range may be illustrated by the 
annexed chart (Fig. 9), taken from a case lately in the Child- 
ren's Hospital ; the child was two years old ; the result was 
recoverv : — 



632 



DISEASES OF CHILDREN. 
Fig. 9. 



F. 

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104 
103 

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TEMPERATURE CHART OF CROUPOUS PNEUMONIA. 

Physical Signs. — In a typical case there will be more or 
less rapid onset of tubular breathing, associated with dullness 
on percussion, the latter often deepening as the case pro- 
gresses, by reason of its frequent association with pleuritic 
exudation, either of lymph or fluid. But it is well to 
remember that bronchial breathing is sometimes slow in 
appearance, and this in cases in which one would expect it 
quickly — viz., those which from general symptoms seem 
very acute. Hillier notes this delay in the appearance of 
bronchial breathing in cases of apex pneumonia. But it is 
not only the delay of the appearance of a morbid quality of 
respiration ; the vesicular murmur is sometimes absent 



PNEUMONIA. 633 

altogether, and the lung appears to be almost silent — so 
much so, indeed, that in some cases it seems possible the 
tubes may become filled with fibrinous coagula, which bar 
the entrance of air into the solidified part. The author has 
lately had a child under his care who illustrates this and 
other points very well. He was a little Jewish boy of six, 
and was admitted with excessively acute symptoms and 
a temperature of 104 . He saw him first on the fourth 
day of his illness, and the respiration was so nearly absent 
over the apex and in the axilla of the left side that he sus- 
pected fluid. A needle was passed into the chest in the 
axillary region, but nothing came out, and at his next visit 
well-marked tubular breathing had developed all over the 
apex of the lung, back and front. The symptoms continued 
severe, although he gradually improved, till the eighth day, 
when, between nine and twelve midday, the temperature 
fell from ioo° to 97 , but it rose again at night to ioi°,and 
after that, for two or three days, rose even to 102 at night. 
A careful examination had revealed a similar absence of 
respiration again over the front part of the lung; but now, 
in addition, the heart-sounds were distinctly louder to the 
right of the sternum than in the proper position, and, 
although the precordial dullness did not appear to be altered, 
the pulsations were decidedly most marked behind the 
sternum. An exploring needle was again passed into the 
chest in the axilla, in the same spot as before, and some pus 
was withdrawn. This was evacuated by incision on the 
fourteenth day of his attack, the chest was drained for a few 
days, and he rapidly got well. Barthez and Sanne allude to 
a case where the respiratory murmur was absent through- 
out, and the disease in consequence thought to be pleuritic 
effusion, but at the autopsy the pleura was healthy and the 
lung entirely hepatized. 

The percussion is often misleading to students. If there 



634 DISEASES OF CHILDREN. 

be pneumonia at the apex, it is usually absolutely dull over 
the disease ; but when there is disease at the base or up the 
back, quite commonly there is a high-pitched tympanitic 
note in front on the same side. It is the so-called Skoda's 
tympanitic resonance. It is best heard in pleuritic effusion, 
but is by no means absent in cases of consolidation. A 
good deal of information is also conveyed to the practiced 
finger by the want of elasticity of the chest- wall, which co- 
exists, it may be, with pneumonic consolidation or with 
pleuritic effusion. A cracked-pot sound may also often be 
elicited under like conditions, only it is not worth while to 
thump the poor child to obtain it, as it conveys no additional 
information. 

One occasionally hears a peculiarly harsh inspiration in 
the earliest stage of pneumonia ; but the respiration is often 
faintly bronchial rather than harsh. The fine dry crepita- 
tion is often absent. When the consolidation begins 
centrally, it may be some days before much is heard at the 
surface of the lung. Careful examination should then be 
made daily over the root of the lung. It is but seldom 
that bronchial breathing, when it exists, cannot be detected 
there, although in this region its presence should always 
be received with caution. 

In the catarrhal form of lobar pneumonia there is often 
some previous history of ill-health — the child is rachitic, its 
chest deformed, or it has frequently suffered from colds and 
coughs, or it has lately had measles, whooping-cough, or 
some other exhausting ailment. The symptoms are acute 
enough ; nevertheless, there is hardly perhaps that painful 
severity about them which may be seen in the fibrinous 
cases. The temperature does not average so high a range, 
though 105 ° or 106 is occasionally reached, the pain is 
less, the skin more moist. In place of a flushed cheek 
there may be lividity, and there will be more bronchitis, 



PNEUMONIA. 



635 



which is equivalent to saying that the respiration will be 
more labored. The child lies propped up in bed, with a 
very rapid shallow respiration — perhaps 100 per minute — 
and dilating alae nasi. The course of the disease is very 
variable, but, as a rule, it ends in no definite crisis. The 
temperature falls gradually, and it has a more prolonged 
course — any time, in fact, from one week to six or eight, 
although here also with careful treatment it will sometimes 
clear up with great rapidity. It is not uncommon thus to 



Fig 10. 




Day of Dis. 



TEMPERATURE CHART OF CATARRHAL PNEUMONIA. 



meet with these cases in wards devoted to whooping-cough, 
and to find the evidences of consolidation all disappear 
within a day or two, and the same applies to the disseminated 
form of broncho-pneumonia. It must also be said that it 
is in whooping-cough that broncho-pneumonia finds its 
most lingering cases. The above chart (Fig. 10), taken from 
a patient in the Children's Hospital, shows the usual 
temperature range ; the child was six years old, the result 
recovery. 



636 DISEASES OF CHILDREN. 

Complications. — Acute pleurisy and acute pericarditis are 
met with ; the former commonly, the latter rarely. 

Diagnosis. — Anything which produces consolidation of 
the lung may resemble a pneumonia in some respects. It 
may be noted as specially worth caution, that fluid at the 
base of the lung, by leading to pressure upon the lung, will 
frequently givQ rise to bronchial breathing at the apex under 
the clavicle, and so to a suspicion of the existence of pneu- 
monia. This is more liable to occur in chronic cases of 
effusion, and therefore in those where the elevation of tem- 
perature is unlike that in pneumonia. Perhaps, however, 
the best method of distinction is to take this axiom, that 
whenever there is evidence of fluid at the base of the lung 
we must distrust any indication there may be of consolida- 
tion at the apex. 

Fluid collected in the front part of the pleura may simu- 
late pneumonia. Goodhart has seen this twice or three 
times, and he has cleared up the doubt on more than one 
occasion by the use of the exploring syringe in the second 
or third intercostal space. 

In pleurisy the temperature is not usually very high ; 
vocal resonance is diminished ; there is often a peculiarly 
damped tubular breathing of sniffling character, and- the vis- 
cera may be displaced. 

Acute caseous consolidation may also. have to be distin- 
guished. The disease is less rapid, the temperature less 
high and more oscillating, and the previous history, family 
history, and general conditions must all be taken into ac- 
count. 

Meningitis may be discerned by its lower and oscillating 
temperature ; by the irregularity of pulse and respiration, 
and by the absence of any quickening of the latter, of dilata- 
tion of the alae nasi, or of physical signs. 

In atelectasis, although the signs of consolidation may be 



PNEUMONIA. 637 

considerable, the fever is little or none ; and there is in addi- 
tion a lividity with' labor of respiration quite uncommon in 
pneumonia. 

Acute tuberculosis gives signs, if any, of acute bronchitis, 
not of pneumonia ; although cases occur in which what 
during life appears to be an apical pneumonia, proves at the 
autopsy to be acute tuberculosis, with much solidification 
of the lung. 

Fibrinous pneumonia, in its acute onset with vomiting 
and convulsions, may simulate scarlatina ; in this case a few 
hours must be allowed for the nature of the disease to 
declare itself. It may closely resemble malarial fever, but 
may be distinguished, according to Holt, by the marked 
morning remission which mostly occurs in malaria, and 
also in the less extent of prostration which the latter shows. 
The onset of acute tonsillitis sometimes gives rise to sus- 
picions of pneumonia. 

Prognosis. — Acute fibrinous pneumonia is rarely fatal. 
But if we take all cases of lobar pneumonia as they occur, 
the mortality is by no means inconsiderable — about one in 
every five, though figures of this kind are not very useful. 
An opinion can only be reliable when based upon a careful 
survey of the condition of the child. An extensive or 
double pneumonia must necessarily be regarded with 
anxiety, however hopeful, until the crisis comes, on account 
of the extent of lung involved ; and any degree of lividity 
of cheeks, or lips, or finger-nails, is of bad omen. 

In acute lobular and disseminated pneumonia the outlook 
will be bad, according as it occurs in rachitic or young chil- 
dren (under twelve months), or is associated with much 
lividity. Convulsions are usually followed by death. 

Results. — If we except caseous bronchial glands and 
tuberculosis, which are not uncommon, there are few re- 
sults of an acute pneumonia. Goodhart once saw a red, 
54 



638 DISEASES OF CHILDREN. 

indurated condition of the lower lobe as the result of sorre 
chronic pneumonic process, after acute pneumonia, prob- 
ably from injury. The affected lobe sometimes becomes 
matted down into a small fibrous mass of gray or reddish 
color, with thick septa throughout it, and the bronchial 
tubes widely dilated. The pleura is generally thick in these 
cases, and it is a question how far the disease may not have 
originated in pleurisy rather than pneumonia. He has also 
seen three cases in which there was considerable fetor of 
breath, so much so as to make him suspect some gangrene 
of the lung, although in all recovery took place. 

Treatment. — In acute pneumonia the child should be 
placed in a warm bed in a well-ventilated room ; it is to be 
warmly but loosely clad in flannel, and the chest enveloped 
in either hot fomentations of spongio-piline or poultices. 
If it be considered advisable to apply counter-irritants, this 
is best done not by putting mustard in poultices, but by 
applying a mustard-leaf to the part for as long as may be 
requisite. It should be fed on milk and beef-tea, and egg 
and farinaceous diet may be added. Internally some simple 
saline, such as nitrate or citrate of potassium, may be given, 
and if there be much pleuritic pain, a dose of Dover's 
powder should be given at once. A child of six or eight 
years may have two and a half or three grains of Dover's 
powder two or three times a day. In very acute cases 
aconite tincture may be given, a drop every hour for a few 
hours. It is useful in promoting perspiration, and generally 
in quieting the severity of the symptoms. If notwithstand- 
ing these measures the temperature remains very high, and 
the child seems to be getting worse, antipyrine or anti- 
febrin may be given, or a bath, warm, tepid, or cold, may be 
resorted to. Of late years very favorable results have 
accrued from tepid and cold baths, but they will not prob- 
ably be of use in the pneumonia of children, as these cases, 



CHRONIC PNEUMONIA. 639 

if they do not speedily get well, become bronchitic, or pus 
forms in the pleura, etc., so that they are not then fit for 
such a plan of treatment. If there be much exhaustion, 
some brandy should be given, half an ounce or an ounce 
in th'e course of twenty-four hours. When any suspicion 
of a bronchial origin attaches to the disease, then the 
atmosphere should be rendered moist by steam, and some 
stimulating expectorant should be given to the child, such 
as a few drops of sp. ammon. aromat., vin. ipecac, syrup of 
Tolu, etc. The chest should be well covered with wool or 
moist applications, and a little stimulant given. 

2. Chronic Pneumonia. — There is very little to be 
said of this disease which is not included under other head- 
ings — for instance, as the result of chronic pleurisy, of rare 
cases of pneumonia, or of atelectasis, one or other lobe 
becomes solidified and ultimately converted into a tough, 
fibrous, contracted relic, with its bronchial tubes thickened 
and dilated. Pleurisy, and particularly empyema, is the 
commonest cause of this condition, save and except it occur 
in the middle lobe of the right lung, which appears to 
undergo some such changes as these in consequence of 
atelectasis, which is so common there. Pleuro-pneumonia 
at the apex is sometimes followed by chronic apical disease 
of a destructive and tubercular nature. Then, again, there 
is the cheesy solidification of parts of a lobe, which may by 
some be considered as a retrograde change in a pneumonic 
lung, or a special form of chronic pneumonia. There is 
one other condition — viz., the syphilitic pneumonia of in- 
fants ; this Goodhart thinks must be rare, as he has only 
seen one or two microscopical specimens, but it has been 
described by various writers under various names, white 
hepatization, perhaps, being that which best identifies it 
Dr. Greenfield has given a careful description of a case 
which was probably of this nature. The child, a female, 



64O DISEASES OF CHILDREN. 

aet. twelve months, died in the out-patient room of St. 
Thomas's Hospital. There was no distinct evidence of 
syphilis, but circumstances in the family history rendered 
its existence extremely probable. The right lung was com- 
pletely consolidated, in a state of full expansion. There 
was slight recent pleurisy, without thickening. The section 
was yellowish-white, the cut surface smooth and slightly 
shining, differing markedly from the ordinary gray hepatiza- 
tion of acute pneumonia. The tissue, being firm and tough, 
exuded but scanty fluid, and minute bands of fibrous tissue 
ran everywhere through it. The microscopical characters 
of the disease show it to have been a condition of extreme 
and active fibrosis, in which the septa and walls of the air- 
vesicles were thickened by a fibro-nucleated tissue in some 
parts to complete obliteration of the pulmonary structure. 

Mr. Symonds has supplied the author with sections from 
another case, undoubtedly syphilitic, for the liver showed 
abundant and remarkable syphilitic hepatitis. The child 
was three months old. In the recent state, the affected 
lung was in a remarkably solid, fleshy condition. Micro- 
scopically, it shows all the features exactly as described by 
Dr. Greenfield — the excessive fibro-nucleated growth, the 
extreme vascularity, dilated thin-walled capillaries running 
in all directions, and an inextricable jumble of fibrous tissue 
with still remaining air-vesicles, the epithelium of which is 
in many parts intact, in some undergoing proliferation, 
which makes it difficult to be sure that the cells themselves 
are not helping forward the process of fibroid growth. Dr. 
Goodhart adds that the histological appearances of the 
earlier stages show also how difficult it is in many cases to 
distinguish altogether between the changes of atelectasis 
and those of interstitial pneumonia. Looking carefully 
over this specimen, it is clear that collapse of the air-vesi- 
cles plays a large part in the process ; and, comparing it 



ATELECTASIS. 64 1 

with others of atelectasis, it seems equally clear that in 
them the hyperplastic process, which may go by the name 
of interstitial pneumonia, is by no means absent, although 
in a less pronounced form. 

3. Atelectasis or Collapse is the disease in which the 
lung; either remains in a fcetal condition or returns to a state 
of non-expansion. More or less it is not uncommon at all 
periods of life, but it never reaches such an extreme degree, 
and therefore never puts on quite the same appearances, as 
in infancy. It affects sometimes a whole lobe ; but more 
often patches here and there, the favorite spots being those 
which are liable to be placed at a disadvantage in the inspi- 
ratory expansion, and these are the anterior margins of the 
lungs, the edges of the lower lobes, and the middle lobe of 
the right lung, which last is a particularly frequent seat. 
Some writers distinguish between congenital and acquired 
atelectasis, but there seems little reason for this, since the 
explanation of all forms of collapse is practically the same. 
Anything which prevents the expansion of a lung, either in 
whole or part, will lead to collapse of the parts hampered. 
We see this in adults most strikingly. Supposing that some 
aneurismal or other tumor presses upon, or some syphilitic 
scar obstructs, a bronchus, the lung becomes collapsed. 
Other changes may perhaps go on also which to some ex- 
tent alter the appearance, but the essential condition is one 
of collapse. Take a case of chronic bronchitis. The tubes 
are full of pus, the air can get out and cannot get in again, 
and a lobular collapse is the result. Take, once more, a case 
of extreme weakness, from old age or fever, or whatever 
you will ; the feeble power cannot command a sufficient 
thoracic expansion, and the base of the lung suffers collapse. 
The air becomes gradually less and less in the unexpanded 
lung till complete airlessness is produced. In infancy, al- 
though the appearances of the lung thus collapsed may 



642 DISEASES OF CHILDREN. 

differ from the collapsed lung in adults, the causes at work 
are essentially the same but with this addition, that while 
in adults the ribs are hardened, the muscles better educated, 
and the expansion consequently conducted under more 
fixed and regular conditions — in infancy the ribs are soft, 
and the muscles act more unevenly ; in fact, the respiratory 
act is in process of being perfected, so that we have a respi- 
ratory type which is sometimes almost undulatory, the 
different parts of the thorax expanding with comparative 
irregularity. This has already been alluded to in mentioning 
the difficulties of auscultation in childhood, but that which, 
in this way, creates a difficulty becomes also a predisposing 
cause of collapse. There is no need to dwell long upon 
the point, it is easily intelligible, and — given such a state of 
the inspiratory act in children — there is a reason for the 
frequent occurrence sometimes of lobar, sometimes of lobu- 
lar, collapse, and for collapse being such a frequent asso- 
ciate of all other diseases of the respiratory tract. It is 
thus that we hear of collapse as the result of chronic nasal 
catarrh, and of enlargement of the tonsils ; of its associa- 
tion with bronchitis and broncho-pneumonia ; of its occur- 
rence in weakly and rachitic children. Further detail is 
hardly necessary ; the immediate causes of collapse suggest 
themselves. For instance, a child is born in an excessively 
feeble state, perhaps prematurely ; it wants the strength to 
take a vigorous inspiration, and the lungs, in consequence, 
remain unexpanded. This is fcetal collapse. Later on, per- 
haps, other debilitating causes are at work, and again a 
gradual expulsion of the air takes place, and then collapse 
of more or less of the lung. At another time, perhaps, it is 
whooping-cough, with a good deal of bronchitis — or some 
catarrhal pneumonia — which leads to it; perhaps some 
severe snuffles or chronic tonsillitis ; often the rickety con- 
ditions in which soft bones and a great tendency to bron- 



ATELECTASIS. 643 

chitis are combined. The student will be well able himself 
to suggest the many conditions under which collapse occurs. 
It must also be remembered that in very young children 
it sometimes comes on with alarming rapidity — a mild 
• bronchitis may perhaps have lasted but a few hours, when 
the child becomes pale, with bluish lips, hurried and shallow 
respiration, and the chest-wall receding during inspiration. 

Symptoms. — When it occurs within the first few weeks of 
life, the child with collapse is of puny build, often wasted, 
and with a weak whining cry. The chest movements are 
shallow, and there may be a want of resonance about the 
bases of the lungs without any decided tubular breathing. 
In cases, also, of great debility there is the same shallow 
respiration, but usually of sudden onset a short time before 
death. In other cases where collapse of the lung is the 
result of pneumonia or bronchitis, the symptoms are mingled 
with those due to these diseases. In cases of extensive col- 
lapse of some duration, the lips may be blue, the fingers 
clubbed, the sternum protruding forward, and the ribs 
deeply depressed and concave outward in the lateral region 
of the thorax and below the nipples. Posteriorly the chest 
is rounded, possibly deformed, and on inspiration the whole 
of the lower part of the chest makes a marked movement 
inward toward the median line, increasing the depression 
already existing. Percussion in such cases may give some 
slight loss of resonance in the basal regions, below the 
scapulae. Possibly, on auscultation, some subcrepitant rales 
may be heard. In cases of long standing the right side of 
the heart becomes dilated and thickened, and the cyanosis 
is not only extreme but persistent. It is remarkable, how- 
ever, how little the heart suffers in proportion to the amount 
of disease that is present. This is explained by bearing in 
mind that cases which seem to be of long standing are often 
not so. A child's chest is so soft and yielding that it will 



644 DISEASES OF CHILDREN. 

alter in shape within a few days, and one of the most dis- 
torted chests the author has seen had assumed that condition 
within a month. Another reason is that defective aeration 
of blood in childhood carries with it defective blood-forma- 
tion, defective nutrition, development, and wasting — and 
many such children are dreadfully thin. The right side of 
the heart is therefore eased of the distention which would 
of necessity follow the same amount of pulmonary obstruc- 
tion in a fuller habit. Atelectasis, by hindering the blood 
current, may prevent the closure of the ductus arteriosus 
and of the foramen ovale. And here it may be mentioned 
that it is more than probable that atelectasis, by leading on 
to broncho-pneumonia and cheesy changes in the collapsed 
parts, is no uncommon source for the dissemination of tu- 
bercle. Dr. Goodhart has seen this so often in connection 
with the middle lobe of the right lung as to have very little 
doubt upon the point. 

Morbid Anatomy. — The lung puts on a variety of appear- 
ances according to the extent of the disease. It may be in 
scattered patches, or confined to the back part of the lung, 
or to one or other lobe ; but the aspect of the atelectatic or 
collapsed part is in all cases much the same. It is shrunken 
below the level of the air-containing lung, or, in the case of 
a whole lobe, there is much diminution in size. It is blue 
or leaden in color upon the surface, and the pleura looks 
thickened; it is not really so; the feeling imparted to the 
fingers being rather that of a flaccid spleen. There is no 
crepitus ; the tissue is quite flaccid, but solid ; and scattered 
throughout are felt a number of more or less shotty bodies, 
which on section turn out to be thickened bronchial tubes 
and septa. The section is of a uniform dark claret color, or 
may be streaked with leaden lines of fibrous septa. It would 
be uniform in surface but that the thickened gelatinous- 
looking bronchial tubes project slightly. The tubes are 



ATELECTASIS. 645 

dilated, and often contain much pus. The diseased parts 
sink readily in water, and will often expand lobule by lobule 
when the lung is inflated by bellows. When the disease is 
one of small disseminated patches, then the fawn or buff 
tint of the spongy lung is studded with small raised irregular 
patches of pellucid-looking bluish or leaden-tinted tissue, 
the central part of each of which is a bronchial tube, with 
its swollen mucous membrane raised above the surrounding 
retracted lung. In these cases there is often much bron- 
chitis (pus in the capillary tubes), and those parts not col- 
lapsed may be emphysematous and over-distended with air. 

The histology of these patches of collapse is even of 
more importance. Take it in its disseminated and earliest 
form, where the small grayish nodules are scattered through 
the lurig, and we find that around the terminal bronchioles 
the pulmonary vesicles are simply flattened together, pre- 
senting the appearance, at first sight, of thickened septa. 
There may or may not be some thickening of the walls of 
the bronchi. But in the large masses of more solid tissue 
the changes are those not only of simple closure, but also of 
interstitial inflammation. The pleura is thick ; the fibrous 
septa between the patches and the adjacent lung — for the 
diseased parts are often shut off from the healthy lung in a 
very definite way by these septa — are much thickened ; and 
not only so, there is clearly considerable activity of cell 
growth in the lymphatic elements around the small bron- 
chi jles, so that collections — such as have been called miliary 
abscesses, though the term is a bad one — are to be seen in 
all parts of the section, and there can also be no doubt that 
the whole area becomes, so to speak, glued together by a 
process of diffused interstitial cell growth. 

These changes seem to be of immense importance with 
reference to the results which may accrue from atelectasis, 
because they seem to show that when collapse has existed 



646 DISEASES OF CHILDREN. 

for some time a chronic interstitial pneumonia results, 
and the foci of cell growth which are scattered about the 
sections suggest, without any knowledge of the clinical 
course, that caseous or degenerative changes are not un- 
likely to follow. That this actually does happen, and that 
these foci are apt to become the source of the dissemination 
of tubercle, is exceedingly probable from the fact that the 
middle lobe of the right lung, a part unusually prone to 
collapse, is very liable to become after whooping-cough — 
a disease particularly liable to produce collapse — the seat 
of cheesy broncho-pneumonia and to be associated with a 
subsequent development of tuberculosis. 

In old-standing cases the right side of the heart is dilated 
and thickened; it maybe fatty; the pulmonary artery is 
dilated and thickened. The liver is large, firm, and'a little 
speckled with fawn-colored points of fat. The spleen is firm, 
and the kidneys have a peculiar india-ruber-like consistency. 

Diagnosis. — The chief difficulty lies not so much with the 
disease itself, as in being certified of the absence of other 
conditions. For instance, in very young infants a purulent 
effusion in one or other chest may easily be overlooked in 
the evident collapse of the lung which it determines. 

Prognosis. — Perhaps no cases can look worse and less 
hopeful than those of extreme atelectasis ; but it is to be 
remembered that these appearances can be quickly produced, 
and may all disappear when the cause of the collapse is 
removed. A chest that has all the appearance of permanent 
distortion, will resume a nearly natural shape as the lung 
beneath becomes gradually expanded. Collapse of the lung 
should, therefore, if possible, i>e remedied as soon as may 
be, for the longer it lasts the more chance is there of chronic 
changes in the lung succeeding, and proving a great -hin- 
drance to the restoration of the thoracic contour. The grad- 
ual recovery of the natural shape of the chest is one of the 



ATELECTASIS. 647 

surest means of judging; and, on the contrary, if the sides 
of the chest remain flattened, and the sternum becomes 
more pointed or bulging, so is the indication that the bases 
of the lungs are not opening out, and that the anterior 
parts are becoming emphysematous. 

Treatment. — All predisposing causes of collapse must be 
vigilantly sought for and treated. . Chief of these are im- 
proper food, bad hygiene, and congenital syphilis. These 
determine rickets, and the soft bones of rickets invite the 
occurrence of collapse. Any indications of debility, in what- 
ever form they may show themselves, must be treated in 
the requisite way. The immediate cause of collapse is 
obstruction to the ingress of air, and bronchitis and 
broncho-pneumonia being — in younger children, and most 
of all in those that are rachitic — the commonest cause of 
obstructed respiration, require early recognition and careful 
treatment. As a rule, the expectoration of mucus from the 
bronchial tubes is best facilitated by alkaline remedies — 
such, e.g., as the bicarbonate of potassium — and by stimu- 
lating expectorants, such as carbonate of ammonium and 
squills. If there be much accumulation of mucus, an 
emetic of mustard and water, or five grains of powdered 
ipecacuanha, may be administered. The child must be 
kept in bed, and in a warm equally-heated room, the atmos- 
phere of which is moistened by the steam from a bronchitis- 
kettle. Unless there be fever, there will be no necessity 
for poultices. Dr. Goodhart objects strongly to the ill- 
advised mummifying that is often seen — a mite of a child is 
perhaps encased in two or three layers of clothes, then a 
flannel bandage, then a poultice, and then perhaps a layer of 
well-greased linen — happy the doctor if it be not tallow. 
How can a weakly child breathe well in such a tomb? 
The chest may be lightly wrapped in a thin wool jacket, 
a warm bath given from time to time, and stimulating 



648 DISEASES OF CHILDREN. 

liniments applied to the surface. It is unadvisable to 
wrap the child up too much, as this provokes much per- 
spiration and reduces the strength. At the same time, in 
fatal atelectasis the body temperature is apt to fall very 
low, and in such cases the infant should be thoroughly, 
but lightly, encased in wool. As soon as possible, 
quinine, iron, and cod-liver oil, or cream, should be ad- 
ministered, and plenty of bathing and friction to the 
muscles of the body, either with simple oil inunction or cod- 
liver oil, the only objection to the latter being its nastiness. 
Electricity has been recommended to improve the tone of 
the muscles and thereby to accelerate the recovery of the 
collapse, but it is a remedy which is not easy of application 
in young children, the sensation frightening them too much, 
and it is better to trust to good rubbing and kneading night 
and morning. 

4. Phthisis. — It is not necessary to discuss the vexed 
question of the nature of phthisis. We may proceed upon 
the statement, which is certainly abundantly proved, that in 
the great majority of cases of destruction of the lung by 
caseous changes, tubercle and cheesy softening in various 
stages are found in the same lung, and, to simplify matters, 
all may be called tubercular. In this respect, phthisis in 
children does not differ from the disease as met with in 
adults, save that in the former case the rule is even more 
absolute, but the pattern or distribution of the disease in the 
lung is less uniform. If we exclude doubtful cases of early 
apical disease in children, it is certainly not common to 
meet with changes which have excavated the lung from 
above downward as is seen so constantly in adults. Any 
one with large experience among children will no doubt 
meet with such cases not so very infrequently, but other 
cases are more common, in which there is no cavitation, or 
the lung is attacked less regularly. These appearances will 



PHTHISIS. 649 

be described directly under their morbid anatomy, but it may 
be mentioned here that such differences as exist largely 
depend upon the physiological standard of growth which ob- 
tains in infancy and childhood. For example, in malignant 
tumors in childhood — whether they be of testis, or kidney, 
or liver, or what not — we do not expect to find a slowly 
growing disease, such as is ofttimes found in adults. The 
processes are active, and the growth, wherever it be, rapid. 
And so it is with tubercle. It runs its course more rapidly; 
and thus we have often more to do with miliary tubercu- 
losis ; with solidification by gray tubercle; with gray tuber- 
cle softening into yellow in a miliary manner, and but 
seldom with any large cavities. In the same way, the 
fibrous forms of disease are less frequent, and other forms 
develop by reason of the proneness in infancy to degenera- 
tive changes in the lymphatic glands. 

The tubercular appearance is generally made much of in 
phthisis in children ; and we are all familiar, no doubt, with 
the description of the pretty child, with its well-formed 
skeleton, its soft hair, long eyelashes, peach-like skin, good 
nails and teeth, and intelligent mien — and with its antitype 
of coarseness, the pale, sallow, stunted, thick-skinned child, 
who goes the same way, albeit, perhaps, by a modified route 
of scrofulous glands. These types have sprung out of expe- 
rience, and should be well remembered. But the student's 
difficulty will be that he is unable to push these definitions 
sufficiently to be of use to him, and as soon as he seeks to 
be enlightened, not upon the tubercular appearance but 
upon the distinctions between it and others — particularly 
fhat which is called by some the rheumatic conformation — 
so that he may be able to say this is one thing, this cer- 
tainly another, he finds his teacher fail him. Types of this 
kind will not bear too close a scrutiny ; it would puzzle 



65O DISEASES OF CHILDREN. 

any one to distinguish many a rheumatic child from a tuber- 
cular one. 

The shape of the chest in tubercular subjects has been 
alluded to by most writers, and Hillier, who is too good an 
observer to be ignored, describes three typical forms : (1) the 
long, circular chest ; (2) the long chest, with narrow antero- 
posterior diameter ; (3) the long, pigeon-breasted chest. The 
author cannot say that he is sure of these ; it has seemed to 
him that a rachitic chest is too frequently the cause of col- 
lapse, and of subsequent cheesy and tubercular changes, to 
make the distinctions of great value. Tubercular chests 
are small chests with the apices contracted. 

Symptoms. — The symptoms of pulmonary tuberculosis in 
children are often most obscure. In the early stages they 
are those which the one shares in common with other 
diseases, and notably that condition to which Eustace 
Smith has given the name of mucous disease. The child 
is pale, thin, capricious in appetite, and has a dry cough ; 
the bowels are irregular, he perhaps may even have worms. 
All these are conditions which are often neglected as tem- 
porary derangements. The temperature is not taken at 
night, and perhaps a case thought to be mucous disease 
develops acute tuberculosis and the child dies rapidly, 
while one as to which suspicions of phthisis are entertained 
gets well. This uncertainty is in great measure due to the 
ambiguity which attaches to the physical signs. It takes 
several very careful and complete examinations to be sure 
of an early tuberculosis, and even then it is sometimes 
impossible to avoid mistakes. The beginner will find, if he 
looks back upon his notes in after years, that a large 
majority of his early cases raised the question of phthisis, 
which subsequent experience solved by the restored health 
of the children. The author, in looking over his own notes, 



PHTHISIS. 63 I 

finds that no less than 152 out of a total of 233 must be 
considered doubtful. There was dullness at one or other 
apex, some clicking crepitation, deficient movement, or 
bronchial breathing, but which has never come to any- 
thing, and in most of which what seemed certain at one 
examination was very uncertain subsequently. One passes 
through phases of experience : at first, all cases are phthis- 
ical ; a riper experience* shows advanced phthisis to be 
comparatively rare. Of the 233 cases mentioned, 64 were 
pronounced cases; 17 others were cases of acute tubercu- 
losis. The ages of such as are detailed are as follows : — 

Acute Advanced Doubt- 

Tuberculosis. Phthisis. ful. 

Under I, 4 2 17 

1 to 2, 3 10 14 

2 " 3, 2 7 10 

3 " 4, o 4 14 

4 " 5. ■ 9 18 

5 " 6 o 8 10 

Jo " 7, 1 2 21 

7 " 8, 1 s 13 

8 " 9, o 3 15 

9 " 10, o 2 8 

Over, o o 13 



No age is exempt from acute tuberculosis. In infants 
only a few weeks old one or other apex will sometimes 
become suddenly dull, and the child die off with the lungs 
studded with tubercle within a short time. Nevertheless, it 
becomes common as the period of dentition is reached, and 
then it is that a disseminated form of tubercle, associated 
with cheesy bronchial glands, is so common. 

Morbid Anatomy. — All forms of tubercle, or rather tuber- 
cular inflammation, are met with in the lungs of children, 
and they are all more or less found together ; but for prac- 
tical purposes, we may distinguish four groups of cases, 



652 DISEASES OF CHILDREN. 

viz. : (1) those in which the disease is chiefly, often entirely, 
a miliary tuberculosis ; (2) those in which there is a con- 
glomerate form of gray and softening tubercle — perhaps 
yellow and gray infiltration — and cheesy bronchial glands ; 
(3) a more chronic form, with cavitation and fibrinous 
changes ; and, (4) cheesy solidification. It is difficult to 
obtain figures to tell the relative frequency of these groups. 
The conglomerate form has been the commonest in the 
author's experience, miliary tuberculosis next so, and the 
others far behind. Some authors describe still further a 
fibroid form of phthisis. Goodhart once met with a pecu- 
liar fibroid form of phthisis without tubercle, in a boy of 
thirteen, who came under the care of Dr. Pye-Smith, and 
the case is recorded by him in the " Transactions of the 
Pathological Society of London," vol. xxxiii. The appear- 
ances in the lungs and liver, which was cirrhosed, were to 
his mind very suggestive of old syphilis. But Barlow has 
met with more than one very similar case, and without any 
history of syphilis ; and no doubt cases of this kind occa- 
sionally happen, the cause of which is obscure. There is, 
however, a more common condition, already described,where 
the base of the lung is solid and the bronchial tubes dilated ; 
but this is certainly most commonly due to some bygone 
pneumonia or pleuritic effusion. 

There is no need to go minutely into the morbid appear- 
ance of the lungs in the several classes of cases, as the 
minute changes do not differ from tubercle, as seen in adults, 
but one or two peculiarities may be mentioned. In the first 
place, the individual granules of miliary tubercle vary much 
in size, and are sometimes so minute as to escape detection 
upon superficial examination. This is particularly the case 
where death has come about rather rapidly by tubercular 
meningitis, and it may serve to impress attention upon the 
fact that the lungs may be perfectly free from any pneu- 



PHTHISIS. 653 

monic changes, and consequently that miliary tubercle of 
this kind is beyond detection by physical examination dur- 
ing life. Its presence can then, indeed, only be suspected 
by the existence of bronchitis in association with other con- 
ditions which make for the existence of tubercle, unless, as 
is possible, the choroid be affected. 

Next, it should be noticed that the distribution of tuber- 
cular disease is more irregular in the lungs of children. It 
is more common to find it distributed throughout the lung 
than at the apex and from thence downward, and it is also 
very common to be able to trace a rough localization of the 
disease about the root of the lung, while there is certainly 
less evidence of the extension by continuity of tissue which 
is so common in adults, though perhaps more of clustering 
around, and extension along the bronchial tubes and septa. 
Again, the existence of cheesy bronchial glands of consid- 
erable size and fleshiness is far more common in children 
than in adults, and last, but not least, there is an allied dis- 
ease which the author met with several times in children — 
never, so far as he remembers, in adults — and to which he 
has given the name of cheesy consolidation of the lung. 
The most remarkable example of this affection that he has 
seen was in a child of two years under Dr. Moxon's care at 
Guy's Hospital. The whole of the left side of the chest 
was dull, and there had been a question of the existence or 
not of pleuritic effusion. At the post-mortem examination, 
nearly the whole of this lung was converted into a solid, 
firm, cheesy mass, quite like an enlarged and cheesy bron- 
chial gland which has undergone no softening. Toward 
the front of the lung there was a little spongy tissue remain- 
ing, and studded rather thickly with yellow tubercles, while 
the other lung was crowded with tubercles. A similar form 
of disease, but less extensive, in which a part of one lobe 
has been diseased, he has seen several times, and it is due, 
55 



654 DISEASES OF CHILDREN. 

he believes, to a gradual growth into the lung from the 
cheesy bronchial glands at its root. 

It need hardly be insisted how these points in the mor- 
bid anatomy are corroborated by, and in their turn enlighten 
and emphasize the physical signs of, pulmonary tuberculosis. 
They show why it is that the physical signs are so often 
obscure, for, if the disease begins by preference at the root 
of the lung, it will long be covered by vesicular structure, 
and the more distinctive features will want that constancy 
which will alone allow of precision in diagnosis. They will 
show, too, how carefully the chest must be examined, inch 
by inch, so that the small patches of disseminated softening 
so often present may not escape detection ; how with the 
enlargement of the bronchial glands in the posterior medi- 
astinum and the extension of disease from them, the inter- 
vertebral grooves must be carefully examined by percussion 
and auscultation, and the resulting sounds most carefully 
weighed with our experience of those of health. 

Allusion has already been made to a child in whose case 
for three weeks great uncertainty existed as to whether his 
disease were typhoid fever or tuberculosis, but which turned 
out to be the latter. The physical signs of disease at the 
root were not of the most distinct, but they were there, and, 
looking back upon the case, it seems probable that with a 
suspiciously wandering dry pleuritic rub, and slight intoler- 
ance of light they were not insufficient to have determined 
the diagnosis had their value been rather more judicially 
examined. These cases frequently require all one's powers 
of mind, a rigorous examination, and the most impartial 
analysis of symptoms, to enable one to arrive at a right 
conclusion. 

The other viscera should always be examined in question- 
able phthisis ; it may be that an enlargement of the liver or 
spleen may be detected, possibly some early tubercular dis- 



PHTHISIS. 655 

ease of the choroid. Such cases as follow are quite com- 
mon. A female child aet. seventeen months : The lungs 
were studded with recent tubercular pneumonia, but in 
addition there was much caseous enlargement of the bron- 
chial glands, numerous tubercles in the liver and spleen, 
general cheesy change in the mesenteric glands, and tuber- 
cular ulceration of the intestines. 

A boy aged one year : The lungs were stuffed with gray 
tubercle in a state of early caseation, the bronchial glands 
were much enlarged, and there were tubercles in the liver, 
spleen and kidneys. 

Complications. — Death occurs in most cases among 
younger children through the outbreak of a general or acute 
tuberculosis, and the extension of the disease to the brain 
and its membranes. Thus we may find tubercular menin- 
gitis, yellow tubercle in the cerebellum or other parts; as 
well as tubercle of the organs already mentioned, of the 
peritoneum, and elsewhere. In older children, where the 
disease becomes very chronic, the same results are met 
with as in adults, viz., lardaceous disease of the viscera, 
fatty liver, tabes, and intestinal or laryngeal ulceration. 

Diagnosis. — In any case of apical disease caution is neces- 
sary in coming to a conclusion. Over and over again the 
physical signs which denote consolidation pass away. Acute 
pneumonia running a rather more chronic course than we 
think it should do, arouses our fears only to dispel them. 
Pleuritic effusion may give rise to rather persistent tubu- 
lar breathing at the apex. This, again, clears up, if we only 
give it time, and it is my distinct belief that there is many 
a local disease at the apex, both parenchymatous and pleu- 
ritic, which arouses exaggerated fears only by its position. 
Localized pleuritic effusions, both serous and purulent, may 
take place below the clavicle as well as at the base, and if 
there be any doubt upon the point, this part as well as the 



656 DISEASES OF CHILDREN. 

base should be explored by the hypodermic syringe. It is, 
indeed, hardly possible to insist too strongly upon the 
necessity of always being on the watch for the presence of 
fluid, and particularly of pus. Empyema is so common in 
children, and so frequently puts on many of the appearances 
of phthisis, that mistakes are quite common. The case 
should be examined repeatedly if there be any doubt, the 
temperature taken regularly, and the body weight at suf- 
ficient intervals. After whooping-cough, too, the physical 
signs are most puzzling. There are plenty of coarse mu- 
cous rales and patches of tubular breathing down the front 
of the lungs and round the nipples, and the excessive 
wasting makes one apprehensive. Nevertheless, we must 
not be too hurried in coming to a positive conclusion. 

Prognosis. — Pulmonary phthisis is in most cases capable 
of improvement, says Gerhardt ; and there can be no doubt 
that many cases, too hastily condemned as cases of con- 
sumption, improve and even get quite well. The frequency 
with which scars, relics of various kinds, calcareous and 
other, are met with in the lungs of older people, proves 
conclusively that many of the changes which constitute 
phthisis are reparable if not too extensive. But perhaps the 
most irrefragable evidence of the possibility of repair of 
tubercle has been offered since the peritoneum has been 
dealt with by the greater boldness and success of latter-day 
surgery. Cases are on record where tubercular granulations 
have been seen upon the peritoneum during operations, and 
the patient has subsequently recovered. There is other 
evidence, hardly less strong. Some time ago the author 
made an inspection upon the body of a lady, past middle 
age, under Dr. Habershon's care, who died of tubercular 
meningitis. Many years before, when a girl, she had been 
supposed to suffer from tubercular peritonitis, and we found, 
in accordance with that view, that the intestines were all 



PHTHISIS. 657 

matted together by old adhesions, and the greater part of 
the mesenteric glands converted into chalky concretions. 
Finding calcareous glands in the abdomen is no uncom- 
mon experience to those engaged in making frequent necrop- 
sies. Therefore it may be accepted as. certain that tuber- 
cular disease is sometimes amenable to treatment. At the 
same time, it is to be remembered that these cases may 
ameliorate for a time, and then suddenly develop acute 
meningitis or general tuberculosis ; and that if they do not 
show any tendency to improvement, the course of the 
disease in children is habitually shorter than it is in adults. 
Treatment. — The essentials of treatment are good feeding 
and good air. The first presents difficulties in all classes of 
life ; the latter chiefly for those to whom money is an object 
of concern. The appetite is generally capricious, vomiting 
is often troublesome, and these patients cannot take fats. 
They do well upon a rich diet, if it can be borne, and they 
should be encouraged to take plenty of good milk, cream, 
suet, and milk and eggs. Plain beef and mutton, nicely 
cooked, are the most nourishing, but in many cases fish, 
oysters, soups, etc., are requisite to vary the diet and tempt 
the appetite. Small quantities of stimulant are of unques- 
tionable value. It may be given as stout, or bitter ale or 
wine, with food. In sucklings, if there be any delicacy 
about the mother, the child should either be fed artificially 
or supplied with a wet-nurse. The air of large towns is 
unquestionably harmful, and children with any suspicion of 
phthisis should, if possible, be removed to a dry seaside 
place, and have as much out-of-door air as possible. Every 
possible attention must be paid to the general health, and 
the rooms in which the child lives and sleeps must be well 
ventilated. Damp is reputed to be injurious, whether asso- 
ciated with warmth or cold. Cold and damp combined are 
certainly prejudicial, and there is also a tendency in these 



658 DISEASES OF CHILDREN. 

cases to weather a winter and then suddenly to deteriorate 
as the showery warm weather at the end of spring comes 
in. Cold weather, if dry, is often most serviceable for early 
cases. The soil should be dry and the place protected from 
the cold north and northeast winds. The clothes must be 
warm. Of drugs, cod-liver oil, by common consent, is of 
great service, and what with tasteless oil, almondized oil, 
biscuits in which the taste of the oil is almost completely 
concealed, and capsules, a great many children with whom 
there was difficulty, can now take it comfortably. It 
may be given in water, orange wine, milk or coffee, 
indeed, in any way that may suggest itself, and the dose 
is to be increased from half a teaspoonful up to two 
or more. 

The following is a very good formula : — 

R. 01. morrhuse, , . . f^iv. 

Ext. malt (dry), ^j. 

Calcii hypophos., 

Sodii hypophos., aa gr. xxxij. 

Potassii hypophos., gr. xvj. 

Glycerinae, f J ss. 

Pulv. acaciie, ^ss. 

Aquae, q. s. adf t ^viij. M. 

SlG. — Two teaspoonfuls three times daily, for a child of six years. 

Such children are often very anaemic, and arsenic is there- 
fore useful. Fowler's solution may be given in three or six 
minim doses, with some simple syrup, or with benzoate of 
sodium, syrup, and water, or — 

R. Liq. sodii arsenitis, 3_j. 

Sodii benzoat, 3 ij. 

Syr. Tolu., f.fj. 

Aquae, q. s. ad f ijiij. M. 

Sig. — One or two teaspoonfuls three times a day, for a child of six to ten 
years. 



PLEURISY. 659 

Many other remedies have been recommended which it 
would be impossible to mention. The most useful are, the 
author thinks, the chloride of calcium — which should be 
given in doses of five to ten grains in some extract of 
liquorice, glycerine and water, three times a day for a long 
period — and iodoform, which he has latterly been trying on 
germicide principles. It must be given cautiously, in half- 
grain or one-grain doses up to two grains or more, with 
white sugar, in a powder. Some children take it very well, 
others badly; some it makes sick, delirious and ill. Dr. 
Sturges speaks well of the hypophosphites of soda given in 
doses often to twenty grains three times a day. 

Counter-irritation may be produced by a mustard-leaf, or 
some linimentum iodi, but in all cases it is to be re- 
membered that a child's skin is very tender and easily 
vesicates. 

For the cough, some simple expectorant may be given, 
and when there is much night perspiration belladonna is by 
far the most reliable remedy. Five drops may be given to 
a child of four or five at bedtime, or a smaller dose may 
be added to each dose of any compatible medicine that it 
may be taking during the day. 

Goodhart once saw fatal haemoptysis in a child of three or 
four years from an aneurism on a branch of the pulmonary 
artery in the wall of a cavity. But haemoptysis is not com- 
mon. Should it occur, small doses of turpentine — e.g., five 
or six drops of the oil — may be given with some mucilage 
of tragacanth, syrup, and dill-water. 

Pleurisy. — Pleurisy is a very common disease, and is a 
particularly important one, if for no other reason than this 
— that the fluid effused is so frequently purulent. The 
author has notes of 149 cases, gathered from all sources of 
his own practice. Of these, 71 were simple, 78 were puru- 
lent. This can, perhaps, hardly be considered a fair aver- 



660 DISEASES OF CHILDREN. 

age, for a hospital physician is naturally likely to see the 
worst side of all diseases. 

The subjoined facts may be of interest :- — 

Age. Simple. Purulent. 

Under I, 6 4 

Between I and 2, 15 13 

" 2 « 3, 11 9 

" 3 " 4, 7 13 

4 " 5> 6 10 

5 " 6, 6 12 

6 « 7, 6 4 

" 7 " 8, 2 5 

8 " 9, . 1 2 

9 " io> . . . 3 3 

" 10 " 12, 4 3 

Not stated, 4 o 

71 78 

Sex. 
Simple pleurisy occurred 31 times in females. 

" " " 40 " in males. 

Empyema " " 35 " in females. 

" " " 43 " in males. 

Fibrinous pleurisy affected the right side 28, the left side 
43 times ; empyema, the right 18, the left 59 times ; one case 
was doubtful. 

The large preponderance of left-sided empyema over right- 
sided, four to one, is worth remembering. 

Pleurisy is usually stated to be most commonly a second- 
ary disease, and, if we consider how many causes lurk in 
diseases of the surrounding structures, we shall not wonder 
that it not unfrequently spreads from adjacent parts. 
Tubercular disease of the lung ; acute and chronic pneu- 
monia ; bronchitis ; dilated bronchial tubes ; disease of the 
bronchial glands ; pericarditis ; inflammatory conditions 
below the diaphragm, such as localized abscesses between 
the liver and diaphragm, or the spleen and diaphragm ; 



PLEURISY. 66 1 

general peritonitis; disease of the spine and ribs — these are 
some of the many affections which may set up pleurisy. 
Less obvious in their actions, but frequent as causes, must 
be reckoned scarlatina and rheumatism — the latter of acute 
fibrinous pleurisy, the former of empyema. The importance 
of both these affections as causes of pleurisy is not fully 
appreciated ; but when all is said with reference to the 
causes of pleurisy, there will remain a large number of 
cases in which it has not been possible to assign any cause, 
and the author is therefore disposed to think that idiopathic 
pleurisy is not so very uncommon. 

Pleurisy may lead to the formation either of lymph, or 
serum, or pus. It is impossible to make any certain distinc- 
tion between those cases in which the exudation is fibrinous 
and those in which it is serous, or, to put it in other words, 
between those in which there is effusion and those in which 
there is none, the reason being, that in children the forma- 
tion of lymph is so active that the presence of fluid is often 
suspected where the exploring syringe shows the opinion 
to have been unfounded. In the treatment of empyema, a 
knowledge of the existence of this excess of lymph is of the 
greatest importance. 

Symptoms. — As a rule they are not very acute, even in 
simple (non-purulent) pleurisy, although there is a definite 
onset. Pain in the side is common, but it often needs to be 
inquired for. Fever, wasting, want of appetite, languor, and 
cough are the more usual symptoms complained of. Head- 
ache, vomiting, convulsions, and diarrhoea are also occa- 
sional symptoms. The time at which the child has been 
brought for treatment has been very variable, from two or 
three days to as many months. This will serve to show 
that the acuteness of onset is liable to vary considerably ; 
and it may be further stated that occasionally the onset is 
so acute as almost to deserve the name of violent — the fever 

56 



662 DISEASES OF CHILDREN. 

being high, delirium considerable, and the pain in the side 
apparently an agony. These cases are quite likely to be 
mistaken for an acute pneumonia, of which, indeed, it would 
be impossible to deny the existence in some measure, and 
they are very likely to be quickly followed by the rapid and 
copious effusion of pus. The temperature in pleurisy is of 
no characteristic type — it is often up to ioi°, 102, ° or 103 
in the first day or two (in the very acute cases higher), in 
the afternoon or evening, and the pyrexia may be prolonged. 
The author has several times entertained unfounded fears 
for the formation of pus from this prolongation of the 
pyrexia. It is difficult to get any large number of cases in 
which the disease has been uncomplicated and watched from 
the commencement as regards this point. In eleven cases 
the temperature has averaged not much over ioo° after the 
first onset, although occasionally in several of these making 
erratic excursions. 

In infants, pleurisy is apt to produce a pinched and col- 
lapsed condition, like peritonitis in the adult. It is also 
difficult to diagnose by auscultation, for in infants the respi- 
ration, naturally harsh, becomes often of a peculiar raucous 
quality, which very closely simulates the rubbing sound of 
an ordinary pleurisy. 

When the fluid is purulent, excepting in the very acute 
cases already alluded to, the onset is still more indefinite 
than when the products are serous. In this respect, again, 
the pleura may be compared with the peritoneum, in which 
the fibrinous or plastic inflammations are very generally 
acute, painful, and not to be mistaken ; the purulent inflam- 
mations are apt to be overlooked, by reason not so much of 
their lack of symptoms as of the vagueness of those which 
occur. Nevertheless, commencing, as the disease often does, 
in acute pneumonia and other evils, a sudden onset is noticed 
in many cases. Of fifteen cases, in eight the child was sud- 



PLEURISY. 663 

denly taken ill; in seven, the onset was indefinite after mumps, 
or scarlatina, or pertussis. Of general symptoms likely to 
be present in empyema, emaciation is often rapid and ex- 
treme. Dr. Goodhart once saw a child, a few months old, 
wasted to the last degree, with a moderate quantity of fluid 
in the left chest. The wasting seemed to be too extreme for 
pleurisy alone, and nothing was done to remove the fluid. 
The child died the next day, and the post-mortem examina- 
tion revealed nothing but an empyema. 

There may also be much pallor, and sometimes a puffy 
appearance of the face, such as suggests Bright's disease. 
This latter symptom is sometimes a most valuable one as 
indicating the existence of fluid in the chest, and, in the 
absence of renal disease or pertussis, pleuritic effusion 
should be thought of. Moreover, it is a symptom which 
indicates a large effusion, and the author has seen cases 
where, except for this sign, the auscultatory and other phe- 
nomena were in favor of pneumonia. This symptom is not 
confined to empyema ; it may accompany any large pleuritic 
effusion. 

Nor is the temperature to be trusted implicitly. As a rule, 
it rises by night ; and the suppurative fever is apt to register 
with particular delicacy the reaccumulation of pus when it 
has been removed by operation. It is by no means uncom- 
mon to find one's self in considerable doubt as to the presence 
of pus in empyemas which have not been tampered with ; 
but after the pus has been evacuated, should it again re- 
accumulate, the thermometer will indicate the fact with the 
most sensitive accuracy. When there is much emaciation, 
and the disease is chronic, there may be no elevation at all. 
Sometimes, while on the whole normal, sudden jumps will 
be made at night ; but, in this, empyema accords with serous 
effusions, which are liable to behave in the same manner. 
It may be said, again, that we must be cautious how, in 



664 DISEASES OF CHILDREN. 

pleuritic effusions, we conclude as to the purulent nature of 
the complaint from the evening rises of temperature, for 
these sometimes occur night after night for a considerable 
period in cases where no pus can be withdrawn. Diarrhoea 
is, also, a valuable sign of the existence of pus in the pleura, 
and the same remark applies to sweating. 

There is one other negative sign to which it is well 
worth while to draw attention, viz., the absence of any 
indication of distress in breathing. Such a thing might 
otherwise be thought impossible with one or other side 
of the chest full of fluid. Yet not only may this be so, but 
even the heart may be considerably displaced without 
symptoms. This is noticed in the more chronic cases, and 
is not difficult to explain. A like phenomenon is present 
in many cases of phthisis, and it is dependent in great part 
upon the compensation which takes place as the disease 
progresses, the emaciated body requiring diminished action 
of the lung. 

There are several difficulties in the detection of fluid in a 
child's chest, which are far less perplexing in adults, and 
pleurisy in children requires therefore the greater care. 
It is frequently overlooked or misnamed. The presence 
of fluid in a child's chest is very often only established by 
the concurrence and correct appreciation and interpreta- 
tion of several slight indications. It is therefore necessary 
to pay attention to slight deviations from the normal. A 
careful inspection tells us that one side is moving less well 
than the other ; the lessened range of movement may be 
considerable — if so, so much the better for the diagnosis ; 
the affected side is rather more flat, or appears generally 
contracted. In very chronic cases the spine may be bent 
toward the diseased side. This contraction of the chest 
may sometimes be verified by the cyrtometer, but exact 
measurements of the size and outline of the chest are diffi- 



PLEURISY. 665 

cult to make and very liable to lead to a wrong conclusion. 
Bulging of the ribs and intercostal spaces is said to be an 
indication of the existence of pus. It is more common to 
find the measurement of the affected side natural, smaller, 
or distorted, than over-distended. 

If the chest be full of fluid, there may be complete dull- 
ness all over the affected side, the heart will be more or less 
displaced (one of the most valuable of all signs of fluid in 
the chest), and the case will present no difficulties. But 
such cases are not common. Fewer mistakes will be made 
if, on the contrary, we look to find modified resonance, not 
dullness, at the apex of the affected side. But comparing 
the one apex with the other, the resonance will not be the 
natural deep resonance, but a high-pitched tympanitic note. 
Whenever this quality of sound is present, the first thought 
should be — Is there fluid at the base of the chest ? 

Pleurisy at the base is the most common cause of dimin- 
ished or tympanitic resonance at the apex, in children. 
Occasionally this is due to pneumonia or to some con- 
solidation at the apex itself. But should there be any 
dullness at the base, stronger evidence than usual is 
necessary to convince us that there is really any disease 
at the apex. 

The tympanitic note at the apex is a physical sign which 
has attracted much attention, and the mode of its produc- 
tion has been often discussed ; it is spoken of sometimes as 
the bruit Skodique, or Skoda's tympanitic resonance. This 
is usually attributed to condensation of the apex of the lung, 
but it is obvious that condensation — partial, not total — may 
be produced in various ways, and the meaning of tympanitic 
resonance by itself would have to be decided upon the bal- 
ance of probabilities. 

Percussion should be gentle. The chest-walls are yield- 
ing, and it is easy in childhood to displace fluid and get upon 



666 DISEASES OF CHILDREN. 

spongy lung beneath, so as to elicit resonance where there 
should be dullness. 

Then again we must be careful, in dealing with the chest 
of a child, how we apply the teaching which has been gleaned 
from adults. The auscultatory phenomena of fluid in the 
chest are — absence of the respiratory murmur ; absence of 
the vocal resonance ; absence of tactile vibration ; and, if the 
compressed lung be near the surface, high-pitched distant 
tubular breathing will be heard. If all these signs are pres- 
ent, the case presents no difficulty ; but such, again, are 
exceptional cases in childhood. What is usually heard may 
be illustrated by a reference to the two most common mis- 
takes which are made by students. The teacher is gener- 
ally told that there is bronchial breathing upon the healthy 
side, or else at the apex of the diseased side. It is quite 
common in these cases to hear all over the affected side a 
soft vesicular murmur of good quality, but deficient in 
quantity. If there were only the one side to judge from, 
the difficulty would be extreme to say whether disease were 
there or not, but, on auscultating the unaffected side, the 
exaggeration of the inspiratory murmur excites attention — 
there is apparent the so-called puerile breathing ; but since 
" puerile " is applied to adult lungs as compared with child's 
lungs, when comparing the normal child-respiration with the 
abnormal the latter must be called " exaggerated puerile." 
The inspiratory murmur is very hoarse and harsh, and the 
expiratory is also rather longer than it should be ; but if we 
gauge the length of inspiration and expiration, the latter is 
not out of proper proportion as to length. 

Again, on the diseased side, one is perhaps told, that there 
is bronchial breathing at the apex, and the case is called 
phthisis. Here the observation is correct; the inference 
from it is wrong. There is often bronchial or tubular breath- 
ing beneath the clavicle on the same side as the effusion, and 



PLEURISY. 667 

this is only what might be expected. The lung is more or 
less compressed by fluid, and therefore prevented from 
expanding; hence the more or less bronchial, nay, even 
sometimes loudly tubular, respiration, just as there is the 
tympanitic resonance. Again, we have to judge not by the 
single sign, but by several combined. The tympanitic reso- 
nance at the apex first puts us on guard ; then, by careful 
percussion, comparative dullness at the same base is detected, 
and on auscultation bronchial respiration and a soft, distant, 
vesicular murmur, with a diminution of the voice-sounds. 
The latter is often interpreted by the student as broncho- 
phony, on the other side. No note need be taken of tactile 
vibration, as it is often difficult to make out anything positive 
about this in children, the voice giving but feeble vibrations 
on either side. We may often get no more pronounced 
physical signs than these, and with them we must be con- 
tent. Good though deficient vesicular murmur may be 
present all over the side which is full of fluid, and unless 
this is remembered there is likely to be a mistake in diag- 
nosis. 

But if we have an opportunity of examining a patient day 
by day, another phenomenon will probably puzzle us, and 
that is the variability of the signs ; an examination one day 
reveals dullness and bronchial breathing ; another day there 
is much less dullness, and what may be considered as good 
vesicular murmur ; one day the chest looks bulging, another 
retracted; and these variations are apt to quickly follow each 
other. This is a feature of chest disease in children. The 
explanation is perhaps not easy to give. It may be due to 
the difference of inspiratory power at various times. 

The presence or absence of crackling or bubbling mucous 
rales in the chest, particularly at the apex, should be noticed. 
In the bronchial breathing of condensed lung from fluid in 
the chest there is often for long an absence of crepitation ; 



668 DISEASES OF CHILDREN. 

and such persistent absence of crepitation is one point, in 
children, in favor of the non-existence of phthisis, which is 
often mistaken for pleuritic effusion. 

If death takes place from serous effusion, some tubercular 
or pneumonic affection is usually at the bottom of it. Some 
hold that a serous effusion is the origin of most of the empy- 
emas, and base upon that belief an argument in favor of 
early paracentesis in the former. The author thinks that 
the balance of probability is against this view, and in favor 
of empyema commencing as such, except in occasional 
instances. 

Morbid Anatomy. — Death from empyema takes place at 
different periods, and the condition of the pleural cavity will 
vary somewhat accordingly. The chest may be full of pus, 
or there may be, besides the pus, much thick caseous lymph, 
or the pleura may be loculated by bands of lymph. Good- 
hart has even seen serum in one cavity and pus in another. 
The lung maybe bound down and quite airless throughout, 
or one part or another may be compressed by fluid. In 
acute pleurisy in children there is often a remarkable 
amount of lymph. This is important, because its softening 
and caseation may possibly, in part, explain the frequency 
of empyema. Moreover, in the treatment of these cases it 
may mislead by preventing fluid coming by the exploring 
syringe, and it frequently proves troublesome by blocking 
the opening of the incision made to evacuate the pus. 

Histological examination shows sometimes simple com- 
pression of the lung; sometimes more or less inflammatory 
cell-growth, running along the septa of the lung from the 
pleura inward ; ■ sometimes nests of cells scattered through 
the bronchial septa, which suggest the possibility of the 
disease having originated in some pneumonic process. 

Complications. — When death takes place during the early 
days of the disease, either after operation or not, pericarditis, 



PLEURISY. 669 

or inflammation of the connective tissue of the mediastinum 
and of the other pleura, or suppurative peritonitis, are the 
more likely causes. In the later stages, death results from 
exhaustion, lardaceous disease of the viscera, and tubercu- 
losis. 

It must further be added, that it is the belief of many that 
pleuritic effusion, particularly if purulent, is the origin of 
many of the cases of chronic pneumonia, fibroid phthisis, 
and dilated bronchial tubes, that are met with in later life, 
and probably this is true for some cases. 

Diagnosis. — There are no useful distinctions, as regards 
physical signs, between pus and serum. The purulent nature 
of the collection may be surmised from the cause — if measles 
or scarlatina, etc., are known to have preceded it, the pres- 
ence of pus is not improbable. Attention should also be 
paid to the general symptoms, of which pallor, pyrexia, 
sweating and diarrhoea are perhaps the more important. 
But Goodhart has seen several cases of simple serous effu- 
sion, in which the temperature has risen regularly every 
evening; some cases of pus, in which the temperature has 
been nearly normal, and pallor and sweating are by no 
means to be relied upon. The question can only be abso- 
lutely settled by an exploration with a hypodermic syringe, 
a trifling operation which does no harm, and generally 
suffices to clear up our doubts. The chest must be care- 
fully examined beforehand, and the needle passed in wher- 
ever it appears that there is fluid, whether this be at the base, 
as is most common, or in the axilla, or even at the apex. The 
author has obtained fluid three times from beneath the 
clavicle when nothing came from other parts. There need 
be no fear of wounding the lung, it would do no harm ; or, 
at any rate, the risk is a mere nothing as compared with 
the importance of settling the question of the existence of 
pus. 



67O DISEASES OF CHILDREN. 

A caution may perhaps be added with reference to the 
conclusion drawn from exploration — viz., that it does not 
always follow that no fluid is in the chest because none 
comes out by the aspirator. There are several conditions 
which now and again militate against the flow of the fluid. 
The lymph within the chest may be abundant and thick, 
while the needle is liable to become choked, or to push the 
lymph before it, and thus may never enter the cavity. . A 
good deal can, however, be learned, even when no fluid 
comes, by the passage of the instrument, and its behavior 
on gentle manipulation subsequently, whether it is in a 
cavity or not. The risk of failure is sometimes lessened by 
using as an exploring syringe one with a needle tube longer 
and of somewhat larger bore than those made for hypo- 
dermic purposes. 

The next most important diagnostic difficulty is to distin- 
guish between phthisis and pleuritic effusion. The two are 
often mistaken, the pleurisy being called consumption ; but 
in treating of symptoms, enough has already been said to 
enable a distinction to be drawn. 

Of other conditions, the chief are chronic consolidation 
at the base from pneumonia and collapse of the lung. These 
may perhaps be distinguished by the increase of voice sounds 
in place of diminution; but, as said, the vocal sounds, whether 
auscultatory or tactile, are of less value in children than in 
adults, and cannot be certainly relied upon. If not, it may 
be necessary to explore by the syringe in these cases also 
before coming to any positive conclusion. It was in a case 
of this kind that the only mishap, and that but a slight one, 
that has ever occurred to the author in the use of the ex- 
ploring syringe came about. Directly the needle was passed 
into the chest the child coughed up, perhaps, two drachms 
of bright red blood. It came so quickly, indeed immedi- 
ately, upon the introduction of the needle, that he feared 



PLEURISY. 67 1 

some large branch of artery must have been punctured, but 
no further ill-results accrued, and no more blood came. 

Prognosis. — Fibrinous or serous pleurisy is but seldom 
fatal, unless some serious disease, such as pneumonia or 
tubercle, be behind it. Some think that it is liable to pass 
into an empyema if the serous effusion is copious, and not 
removed early ; but while allowing this to be possible, 
nothing is known to support the view. As a rule, simple 
pleurisies clear up with great rapidity. The fluid in these 
cases is not often excessive. When there is excess of fluid 
it is more often than not already purulent. 

The prognosis in empyema is, however, more grave. 
Naturally, a chest full of pus must be a serious evil. If let 
alone, it tends to spoil the lung by prolonged pressure and 
inflammation, or by burrowing into the lung. If it should 
make its way externally, the chances are better, but best of 
all are its early recognition and evacuation. Of late years 
this treatment has been very successful. Dr. Goodhart states 
that in a series of fifty cases either under Dr. Frederick Taylor 
or himself, in the last five or six years (and he has not in this 
by any means summed up his entire experience), forty-two 
have quite recovered, a sinus remained in three, and five 
died. Of these last, however, it is only fair to say that one 
had suppurative pericarditis as well as empyema ; in another 
the empyema was double ; a third was due to a foreign 
body in the bronchus and septic pneumonia ; the fourth had 
a huge collection, with an eighteen months' history; and the 
fifth was doing well, when it caught measles and died of bron- 
cho-pneumonia. 

Treatment. — Fibrinous and serous pleurisy are best treated 
by opium in moderate doses to relieve the pain and the cough 
and salines, such as the nitrate and citrate of potassium, or 
some effervescing saline, to act as a diuretic and diaphoretic. 
In the acute stages, warm fomentations are in most request; 



672 DISEASES OF CHILDREN. 

but cold compresses are also useful, changed every few min- 
utes. In older children, the side should be firmly strapped, 
and warmth or cold can be applied by means of compresses 
or the ice-pack outside the strapping. 

After the first few days, iodide of potassium, in one- or 
two-grain doses, should be given with some syrup of the 
iodide of iron, the bowels being kept gently open by some 
mild aperient. It sometimes happens that although the 
general symptoms clear up rapidly, the dullness remains 
behind ; but this is only to be expected when we consider 
the large amount of lymph which is sometimes found. It 
is best, under these circumstances, to apply counter-irrita- 
tion externally by means of the liniment of iodine ;* but 
more is probably to be gained by exercise and plenty of 
fresh air, by which it may be hoped to promote free expan- 
sion of the lungs. When the disease is acute and the 
effusion excessive, paracentesis may be advisable ; if so, it 
is probably better to draw off a moderate quantity than to 
aim at removing the whole. But we are not advocates for 
paracentesis merely because of the presence of fluid. There 
is evidence in abundance that serous effusions clear up 
rapidly by natural processes ; there is evidence in abun- 
dance, also, that the simple presence of fluid is not likely in 
childhood to harm the lung if the amount be not large and 
its duration be kept within a moderate limit of three or 
four weeks, and provided that the fluid shows signs of 
gradual diminution. When the effusion takes place rapidly, 
when it is in great excess, with displacement of heart, fever, 



* Linimentum iodi, Br. P., contains — 

Iodine, 1% ounce 

Iodide of potassium, y? ounce 

Camphor, ^ ounce 

Rectified spirit, 10 fluid-ounces. 



PLEURISY. 673 

pallor, and puffiness of the face, such are the symptoms 
which indicate the necessity for aspiration. 

We have next to deal with the treatment of empyema, 
and we shall be the better prepared to consider the question 
in any individual case if we remember that the pleural cavity 
is one which has difficulties and dangers all its own. The 
mobility of the lung, the rigid nature of the thoracic wall, 
the nooks and crannies in which pus can form, all would 
seem to combine to make efficient treatment impossible. 
Yet it is remarkable — if only the one difficulty of inefficient 
drainage can be combated, and the cavity kept free from 
sepsis — how successful the treatment becomes. The author 
has seen a pleural cavity six weeks after the evacuation of 
an empyema so perfectly obliterated by silky adhesions of 
connective tissue, that, without the knowledge, one could 
not have believed that any disease could have existed in 
recent years. 

There are other less brilliant results, no doubt, and not 
infrequent, too, such as the persistence of a fistula and dis- 
charge, until the lung is spoiled, and the child dies ex- 
hausted with lardaceous viscera ; but these are far less 
common now than formerly, and will probably be even yet 
further diminished in number as the frequency of empyema 
is recognized and its presence detected early. 

But now for the actual treatment. Having assured our- 
selves by exploration of the presence of pus, how is it to be 
treated ? It may be left alone, or it may be removed in one 
of several w r ays. 

1. The chest may be aspirated. 2. It may be tapped by 
trocar and canula, drawing off as much fluid as may be neces- 
sary, or as much as is possible. 3. After tapping, an india- 
rubber tube may be passed through the canula into the chest, 
and the canula being withdrawn, the tube allowed to remain 
as a siphon. 4. The old plan, and a very good one, may be 



674 DISEASES OF CHILDREN. 

adopted, of making two openings in the chest, one above 
and one below, and passing a drainage tube in at one and 
out at the other. 5. And, lastly, a free incision may be made. 
Each of these methods of removal has its advocates, and all 
are useful on occasion. But all the author's latest experience 
has gone to convince him that, as a rule, a free incision in 
the seventh or eighth intercostal space — the position of the 
opening being mostly determined by the position of the 
pus — is an operation which is not attended by any serious 
risk, and, combined with free drainage afterward, by means 
of as large an india-rubber tube as can be inserted, is very 
successful. 

Goodhart is inclined to insist less strongly than formerly 
on the position of the opening ; it may be made wherever 
the exploring needle indicates that the pus is easily reached, 
either in the front, side, or back of the chest. 

But it may not be always advisable in very young, deli- 
cate, or exhausted children, to open the chest thus. The 
incision is not altogether a trifle, and it may seem better 
every now and then either to aspirate or tap. 

In localized empyemas and in cases of rapid onset it may 
sometimes be advisable or necessary from surrounding cir- 
cumstances to aspirate the chest. Bowditch has had great 
success with simple aspiration. Barlow has also recorded 
good results, and the author himself has had five cases in 
which nothing more than aspiration was required. This 
plan will find its most frequent application in very young 
children, and where the pus is in very small quantity. 

If the pus is in large quantity, it is of little use to try 
aspiration except as a preliminary to some more radical 
measure ; and it is a fatal mistake to aspirate in such cases 
time after time, as is sometimes done. To do this is to take 
the surest means of converting the sac into a chronic abscess, 
and to .invite a permanent fistula and collapse of the lung. 



PLEURISY. 675 

The siphon plan is of use in cases where the materials 
necessary for incision on the antiseptic method are not 
ready to hand, or where, for other reasons, aspiration 
or incision are not judged to be the best operations for the 
case. It is also of use when, owing to extreme disten- 
tion of the cavity and displacement of the viscera, the rapid 
evacuation of the pus by incision seems to threaten some 
risk. The two openings and a connecting drainage-tube 
offer some advantages when there is a difficulty in thor- 
oughly draining the chest. And in such cases where the 
empyema points spontaneously, it may perhaps be left 
alone or opened at the spot toward which the pus is tend- 
ing. In private practice it will often happen, from various 
circumstances, that the treatment has to be modified to suit 
those circumstances — in other words, we are not always 
able to act up to the most modern light as regards a sur- 
gical operation, and Goodhart has sometimes been com- 
pelled to advise tapping with a large trocar, and leaving a 
simple tube in the opening thus made. This is not a plan 
that is to be recommended ; but, under strict antiseptic pre- 
cautions, it maybe completely successful. The siphon plan 
alluded to above requires a soft india-rubber tube of some 
length. One end of this is passed into the chest, and the 
other lies in a vessel containing some antiseptic fluid, such 
as weak carbolic lotion. It is convenient to divide it in the 
centre, and connect the divided ends by a piece of glass 
tubing ; in this way the perfect action of the siphon is 
readily gauged. This plan has no doubt some not unim- 
portant advantages over some others : the operation is easy 
of performance ; it is not a very painful one ; it is conveni- 
ent if the chest requires washing out ; and, if all goes well, 
the chest is kept sweet. But empyema in children is very 
liable to be accompanied by large flakes of lymph in the 



676 DISEASES OF CHILDREN. 

cavity, and the tube becomes blocked and has to be re- 
moved, so that incision is to be preferred as giving a freer 
exit to such material. 

Next, one or two points with reference to the operation 
of incision. If the chest is very full indeed, the operation 
may be followed by severe suffocative dyspnoea. Taking 
away a quantity of fluid somewhat suddenly must of neces- 
sity disturb the intra-thoracic circulation, which has in 
many cases become accommodated to the abnormal state, 
and a risk is run thereby of the occurrence of a sudden 
oedema of the sound lung, which has not so very rarely 
proved rapidly fatal. Therefore, in cases of extreme effu- 
sion, it may be advisable to make a preliminary aspiration 
before draining the chest thoroughly; or, if incision be 
decided upon, the pus should be allowed to drain away 
slowly for the first few hours. Its rate of exit can easily be 
regulated, for the ribs are so close together, in any case, that 
the difficulty lies in obtaining a sufficiently free outlet by 
whatever means may be adopted. 

During the operation great care should be exercised to 
insure that the opening between the ribs is as free as pos- 
sible ; and both then and for the first day or two during the 
dressings every facility should be afforded for the escape of 
the masses of fibrinous coagulum so commonly present. 
This is best done by opening the aperture by forceps, while 
the drainage-tube is withdrawn, and extracting anything 
that may be within reach. Except in this way, the chest 
cavity is to be meddled with as little as possible ; and all 
washing out, though, unfortunately, it must be resorted 
to occasionally if the cavity becomes foul, is to be depre- 
cated. 

Washing out the pleura is as difficult of efficient accom- 
plishment as washing out the bladder. In either case sepsis 



pleurisy. 6yy 

must be prevented. When once the cavity has become foul 
there is small chance of restorative action by any such means. 
Moreover, it is not without risk ; it may lead to sudden 
death. A number of cases have of late years been placed 
on record in which a sudden comatose state culminating in 
death has come to patients while having their pleura irri- 
gated. The cause of such a calamity is in much obscurity 
— by some it is considered to be embolic, by others to be 
due to some reflex nerve-storm due to interference with the 
pueumogastric; but the facts are quite certain, and they 
must be the mainsprings of our action or inaction. Next, 
the drainage-tube is to be dispensed with as soon as possi- 
ble. Inefficient drainage is, no doubt, the cause of many a 
bad result, but it is equally true that many a case becomes 
intractable from the too prolonged use of drainage-tubes. 
After the pus has been removed, the auscultatory signs show 
conclusively in most cases that the compressed lung soon 
begins to do a considerable amount of work. Vesicular 
breathing may often be heard to within a very short distance 
of the aperture in the chest-wall ; add to this some ascent 
of the diaphragm and some falling-in of the chest- wall, 
which is generally quite a noticeable feature of such cases, 
and it is obvious that the cavity soon becomes much reduced 
in size. A probe or a considerable length of drainage-tube 
can no doubt be inserted, but this proves nothing as to the 
existence of a large cavity. The instruments make a pas- 
sage for themselves in the as yet unconsolidated lymph. 

In operating a free incision is made between the ribs, large 
enough linearly to allow of the passage of the finger into 
the cavity, should the space between the ribs permit it. 
This is free enough to allow of the introduction of a large 
drainage-tube and something over, and thus, to all intents, a 
double opening into the chest is secured. After removing 
57 



6yS DISEASES OF CHILDREN. 

some of the pus and any masses of lymph that may be within 
reach, some four or five inches of a freely perforated, stout, 
but soft, red india-rubber drainage-tube which has been 
well soaked in carbolic acid is then passed into the chest, 
and secured in position, and the usual antiseptic protectives, 
as advised by Professor Lister, are placed over all. The 
dressings should be removed twice in the first twenty-four 
hours, and once daily for the first few days afterward, and 
the drainage-tube in the chest is to be daily shortened, so 
that at the end of five or six days only an inch or an inch 
and a half remains. This is length enough for keeping the 
external aperture patent, and the internal parts are no longer 
interfered with. If the discharge remains very slight, the 
tube can be removed altogether, the temperature being 
watched closely ; so that, if after its removal any evening 
rise occurs, it may be at once re-inserted. It not unfre- 
quently happens that with early removal such as this it 
becomes necessary to re-insert the tube for a time, but this 
is a less evil than its prolonged use — indeed, no additional 
evil at all, if the temperature be taken as a guide. This will 
give sufficiently early notice to prevent any accumulation. 
Next, a word as to Listerism — it should always be adopted 
in the first two or three weeks. Practically it is continued 
at the Evelina Hospital till the child leaves, and that may 
not be for some weeks ; but the author believes that its 
continued application is sometimes harmful in keeping small 
cavities open. Therefore, when there is but a small cavity 
remaining, it is better to send the child to the purest pos- 
sible air, and apply nothing but a little iodoform and marine 
wool, which should be frequently changed. 

It is not advisable to keep such cases too long in bed ; a 
week or ten days after the empyema has been opened the 
child may sit up, and even sit out in the open air if possible. 



PLEURISY. 679 

Last, and most important of all — unfortunately for hos- 
pital patients a treatment that cannot often .be utilized — 
comes sea air. 

This is, in short, the best that can be done for such cases. 
But we must bear in mind that the conditions are such as 
to present obstacles in many cases to successful treatment, 
and empyema must therefore always be liable to prove dis- 
appointing. If we have to deal with an abscess in most 
other parts the pus can be entirely evacuated, and the walls 
of the cavity can be adapted to each other and kept in 
position. In the chest it is not so ; we are dependent upon 
contraction of the chest-wall, ascent of the diaphragm, 
granulation from the pleura, and expansion of the lung ; 
and it is hardly to be expected that repair conducted under 
such adverse circumstances should present no difficulties ; 
we should the rather expect that the cavity is more likely 
to be diminished in some directions, obliterated in some, 
and so cut up irregularly as to render complete drainage a 
matter of great difficulty; and so it too frequently is. But, 
nevertheless, it can be said that, recognized early and treated 
secundum artcm, the treatment of empyema, from being one 
of the most disheartening, has become one of the most suc- 
cessful and gratifying of surgical operations. 

Of late, finding that the results of the treatment of em- 
pyema have not quite come up to their expectations, some 
have advocated the excision of a portion of one or more 
ribs, with the object of facilitating the falling in of the chest 
and of obtaining more free drainage. Applied to the majority 
of cases the practice is unnecessary, and therefore bad. The 
treatment of empyema by incision, as just said, is as suc- 
cessful as it can reasonably be expected to be, if the cases 
are taken in good time ; and in cases which have been long 
overlooked, or which have been long discharging, whatever 



680 DISEASES OF CHILDREN. 

we may do is, in the majority of instances, unavailing. The 
large aperture that is made by the removal of the rib quickly 
closes up, and we are no better off than before. Dr. Good- 
hart is prepared, however, to admit that in long-standing 
cases, or in cases which have been subjected to much treat- 
ment before the final free opening has been made, the 
question of excising part of the ribs may very properly be 
entertained. 



PART VIII. 
DISEASES OF THE HEART. 



i. Heart Disease. — In studying diseases of the heart 
in children, it is necessary to be aware of a few preliminaries. 
The heart's action is more rapid than in adults. It is not 
necessary to burden the memory with the precise data for 
particular periods, but it will suffice to remember that at 
birth it is about a hundred per minute, for the first two years 
it quickens up to one hundred and fifteen or one hundred 
and twenty, and that subsequently it gradually slows again. 
From two to six it remains about a hundred, and then grad- 
ually drops to seventy or eighty. In early childhood there 
is a good deal of difference — often as much as twenty beats 
per minute — between sleeping and waking ; the heart, of 
course, beating slow in sleep. This is naturally a matter of 
great importance in disease, for if the heart's action can be 
thus reduced, as much sleep as possible will certainly be 
advisable in cases in which the heart is diseased, and needs 
all the rest that can be obtained for it. This difference is 
said only to apply to young children. One cannot, however, 
dogmatize on this matter, for it would appear, from some 
observations made by Dr. Newnham at the Evelina Hos- 
pital, that the amount of slowing is subject to some varia- 
bility. In several cases it was noticed to be three or four 
beats quicker during sleep ; although on the whole there was 
a well-marked reduction of four or six beats, and sometimes 

68 1 



682 DISEASES OF CHILDREN. 

as much as thirty beats per minute ; and this not confined by 
any means to the youngest children, but to those of seven, 
eight, and nine years. The heart's action is also less regu- 
lar in its rhythm — one beat will be feeble, the next strong, 
and so on. The point of this is chiefly, as Meigs and Pep- 
per remark, that caution must be exercised in drawing con- 
clusions in cases of doubtful meningitis, in which disease an 
irregular pulse is one of the most valuable diagnostic indi- 
cations. The heart's action is often more diffused upon the 
surface and visible than in adults ; the position and the im- 
pulse with regard to the nipple is more variable, and the 
impulse is often higher than normal in the fourth interspace. 
The precordial dullness is a little larger. Perhaps this 
would not be so in children of absolutely healthy standard ; 
but so many suffer from moderate chest distortions, from 
bygone collapse of the lung and chest wall, that the lung 
which should cover the heart more thoroughly is less 
expanded than natural. The heart sounds are usually 
more tic-tac — that is, less sustained, than in adults; al- 
though, given an adequate cause — acute Bright's disease, 
for example — they will become thick and laboring as in an 
adult. This is well worth notice, for the author has often 
had his attention called to the existence of albuminuria by 
the peculiar lengthening and laboring quality of the first 
sound. This is perhaps the more striking when one has to 
confess that any corresponding changes in the pulse can 
but seldom be shown to exist. It is very difficult, indeed, 
to gain reliable information as regards volume and force, 
and with the sphygmograph one meets with little but dis- 
appointment in children. 

There is not much that is peculiar to childhood in dis- 
eases of the heart, excepting, of course, the various forms 
of congenital disease ; but there are one or two points which 
are worth remark, and even where the diseases follow the 



DISEASES OF THE HEART. 683 

same lines as those of adults, the obscurity of origin of 
many cases in grown-up people makes the various forms 
of heart disease in early life of considerable etiological 
value. 

Steiner makes the statement that a useful rule in diag- 
nosis is to consider all heart affections occurring under four 
years of age of congenital origin, and that only after that 
age do the acquired diseases make their appearance, because 
their chief exciting cause, rheumatism, is seldom met with 
in children under four years of age. But this rule must 
not be insisted upon too rigidly. Heart disease is, no 
doubt, much more common over four than under ; but those 
cases which occur in younger children must not be too 
hastily assumed to be of congenital origin, if by congenital 
we mean such conditions as are due to malformation rather 
than to disease. Taking Goodhart's own cases, the figures 
stand thus : — 

Rheumatic heart disease, 134 cases. 

Non rheumatic, or with no history, 55 " 

The heart disease of chorea may be excluded, because it, 
no doubt, seldom occurs before four years of age. The age 
is noted in 169 cases of these : — 

u^de" * 3 4 5 6 7 8 9 xo xx x, x 3 *£? Total. 

io 2 4 9 io 19 12 16 14 20 18 11 4 20 169 

Sixteen cases, therefore, occurred under four years of age. 
Of these, twelve, or three-fourths, it is true, are headed as 
congenital ; but of the twelve cases so-called, five were asso- 
ciated with a simple systolic bruit, which, in an adult, would 
certainly have been attributed either to mitral or tricuspid 
regurgitation ; and no doubt we are too apt to conclude 
that when cardiac murmurs are present in infancy, there is 



684 DISEASES OF CHILDREN. 

some malformation of the heart. The following case may 
point this remark : — 

A male child, aet. two months, was admitted into the 
Evelina Hospital for cough and stomatitis. It was illegiti- 
mate, brought by a woman in charge, who stated that it had 
been ill three weeks. It was in a moribund state, and very 
thin. Temperature 103 . Respiration and pulse not to be 
counted. There was a loud systolic bruit heard at the 
apex and all over the right side of the chest. It died in a 
convulsion within a short time of its admission. At the in- 
spection, the mitral edge was thick, and on its surface were 
abundant inflammatory granulations, uniformly distributed 
round the orifice, and quite sufficient to interfere with its 
efficient closure. 

Notes could be given of several other cases of infants but 
a few months old in whom the physical signs were in favor 
of simple mitral regurgitation. It may also be added that 
Mr. Bland Sutton, in a recent paper read before the Royal 
Medico-Chirurgical Society upon the value of the systematic 
examination of still-born children, has published a case of 
recent endocarditis in an eight months' foetus, the pulmo- 
nary and aortic valves showing soft vegetations, and the 
mitral being much puckered. This distinction between 
disease and malformation, though not always practicable, is 
clearly an important one. 

Causes. — Of two hundred and forty-eight cases of heart 
disease in early life which have passed under the author's 
notice, either at Guy's Hospital or the Evelina Hospital for 
Children, twenty occurred in the course of acute rheuma- 
tism ; one hundred and thirty-four are set down as rheu- 
matic (occurring, that is to say, either as the sequel of actual 
rheumatism, or in families with rheumatic history) ; fifty- 
nine gave a history of chorea, or were actually choreic, at 
the time they were under treatment ; and fifty-five could not 



DISEASES OF THE HEART. 685 

be attributed to any definite cause, if we except seven, or, at 
most, twelve, which may have been congenital. 

As regards causes of valvular disease other than rheuma- 
tism and chorea, of which there must surely be very many, 
though no one at all approaches either of these in impor- 
tance, scarlatina probably comes first ; but other exanthems 
occasionally lead to endocarditis, and diphtheria, pneumonia, 
pleurisy, typhoid fever, syphilis, and pyaemia are all occa- 
sionally to be found in its company. 

It is, moreover, interesting to note how valvular disease is 
more common in females than in males all along the line, 
not only in the rheumatic and choreic cases, but also in 
others : — 

Females. Males. Total. 

After rheumatism, 89 45 134 

Choreic, 45 14 59 

Other, 33 22 55 

167 81 248 

Next, as to the nature of the valvular disease: — 

Non- 
Rheumatic. Choreic. rheumatic. Total. 

Mitral, 79 39 29 147 

Aortic, 3 7 1 11 

Aortic and mitral, . . 8 1 1 3 22 

Doubtful, 44 2 10 56 

Congenital — — 12 12 

134 59 55 248 

This table shows how large a proportion mitral disease 
bears to other forms. Eleven cases only out of the total 
were simple aortic disease, twenty-two others had both 
aortic and mitral disease. Doubtful cases form a large group , 
This heading is not intended to indicate that the existence 
of disease was doubtful, but only that its exact nature was 
not to be precisely determined. Under it are classed all cases 

58 



686 DISEASES OF CHILDREN. 

of thick sounds, thumping action, displaced heaving impulse, 
in some of which no doubt the mitral was at fault, and in 
others an adherent pericardium was suspected. But one 
cannot doubt that if mitral disease had its due, many of this 
group would fall to its share ; and this would raise the pro- 
portion which mitral disease bears, so overwhelmingly, as 
to reduce all other forms to a numerical insignificance. If, 
next, we inquire further into the form of mitral disease, in 
five cases a pre-systolic bruit existed, and ten others proba- 
bly had a contracted mitral, while doubtful cases are in- 
cluded in the group devoted to them. Therefore, not only 
can it be said that mitral disease is the common form of 
heart disease in childhood, but that mitral incompetence, or 
mitral regurgitation, is by far the commonest form of mitral 
disease. Stress is placed upon this, because it is said and 
taught that there are two different forms of mitral contrac- 
tion, and one of them is of congenital origin. If so, it should 
show itself in childhood ; whereas, in very young children, 
mitral stenosis is almost unknown, whether we look for it 
at the bedside by auscultation or in the post-mortem room. 
The author has long been looking for such a specimen in 
children under five years of age, and has never yet seen one. 
Mitral regurgitation is common enough, but mitral stenosis 
is not found until we come to deal with children of eight or 
nine years of age. It is not at all common at that age, but 
after that it becomes common as years advance, and, as we 
all know, it is one of the commonest affections of adult life. 
A girl of four years was in hospital from June^to Novem- 
ber, 1882, with acute peri- and endo-carditis, and acute 
pleurisy, with consolidation of the base of the left lung. Her 
illness was attributed to cold caught six weeks before her 
admission, and neither personal nor family history of rheu- 
matism could be elicited. After she left the hospital no 
more was heard of her until thirteen months later she came 



DISEASES OF THE HEART. 687 

in to die. There was still, as there had been when she left 
the hospital the previous year, a loud systolic mitral bruit, 
and the impulse of the heart was inside the nipple. Con- 
vulsions were the immediate cause of death. 

The inspection showed a large heart with an adherent 
pericardium. The mitral valve was considerably thickened, 
but the aperture admitted one finger. The aortic valves 
were thickened. 

This case is given because it is typical of the cardiac 
changes one may expect to find in young children, and of 
the conditions which lead to death. The pericardium 
was firmly adherent, and the heart large and no doubt 
dilated. The mitral valve was considerably thickened, but 
not yet substantially contracted, for it admitted one finger, 
which is a fair capacity for the heart of a child five years 
old. 

Acute pericarditis occurred in twelve cases in all — in six 
associated with acute valvular changes in chorea, in six with 
acute rheumatism. In comparison, therefore, with endocar- 
ditis, it would seem to be uncommon.* But the student 
must remember that it is found in many other conditions 
than these, and, perhaps as commonly as in any, in those 
acute inflammations of bone which are not infrequent in 
childhood and adolescence, and which go by the name of 
infective osteo-myelitis. Such cases almost always suffer 
from abscesses in the heart, and, as a natural consequence, 
acute pericarditis follows, and should the patient live long 
enough, pus collects in the sac. Pericarditis may also be 
met with after scarlatina (when, perhaps, it is rheumatic) ; 

* Upon this point the author notes : " I am now only dealing with my series 
of hospital cases. I have seen it more commonly than these figures indicate, 
but that is probably, as I have remarked for empyema, because outside the 
hospital, more than inside, the practice of the hospital physician lies among 
the worst cases, not those that are mild." 



688 DISEASES OF CHILDREN. 

by extension of disease from the neighboring pleura ; and 
occasionally, but very rarely, though more often in children 
than in adults, with a tubercular affection of the serous 
membrane, and as a sequel of acute Bright's disease. 
Should there at any time be evidence of a large accumula- 
tion of fluid in the sac, the possibility of it being purulent 
must be considered, particularly if the inflammation have 
extended from a left-sided empyema, or be secondary to the 
existence of tubercle. A septic form of pericarditis is de- 
scribed by most authors as occurring in the new-born infant, 
and originating in the umbilical sore. 

Acute peri- and endo-carditis are noteworthy in children 
as more liable than in adults to lead to a rapidly fatal termi- 
nation. Whether the inflammation is more severe in child- 
hood may perhaps be doubtful ; but at any rate the heart 
swells more quickly, its cavities dilate more readily, and a 
very few days' illness may determine a fatal issue. The 
author once had a case of a young man, above the age, it 
is true, with which we are now concerned, who, to all 
appearance, had a healthy heart four weeks before his death. 
He was seized with acute pericarditis, and at the post- 
mortem the heart weighed 19 ounces. This looked at first 
like acute hypertrophy, and no doubt in part it was ; but 
subsequent experience had made him think that the criti- 
cism of Dr. Coupland, made at the time the case was 
recorded, was a just one, and that, as he suggested, some- 
thing of the nature of acute swelling had taken place. In 
children an acute inflammation of the heart of this kind 
takes place — pericardium, muscle, and endocardium, all are 
involved — the heart swells, rapidly enlarges, and the ventri- 
cular cavities dilate, and then there follows that contracted 
leaden consolidation of the bases of the lungs, a condition 
very common in children, which is neither simple collapse, 
nor simple oedema, nor simple pneumonia, but probably 



DISEASES OF THE HEART. 689 

something of all these, and which is an excessively alarming 
and dangerous condition, because it is an indication of a 
sorely stricken heart. 

The physical signs in such a case are not without interest. 
The heart's action is generally of great rapidity, the anterior 
wall of the chest will enlarge rapidly in the precordial 
region — protruding, in fact, before an enlarged heart — the 
pulmonary second sound will be loud, and the systolic 
sound at the apex will be replaced by a confused roar. 
Should there happen to be much effusion, the conditions 
will necessarily be modified thereby, and there will be in- 
crease of the precordial dullness, particularly upward and 
to the right, and the impulse will become less violent and 
less diffused. It is but seldom that pericardial effusion 
causes either impulse or friction sounds to disappear alto- 
gether. 

But there is another form of heart affection than those 
mentioned, and probably one of no mean importance — viz., 
simple dilatation. West records several such in which no 
disease of the valves was found post-mortem. Goodhart 
has seen it repeatedly ; more especially, however, in con- 
nection with post-scarlatinal nephritis. He does not, how- 
ever, suppose that this is the sole cause of the condition. 
On the contrary, when we consider how liable the cardiac 
muscle is to suffer in its nutrition in prolonged anaemia — a 
common affection in children — how it has been shown to 
undergo dilatation, independently of nephritis, after scarlatina, 
measles, typhoid fever, and septic conditions of all sorts — 
nay, how it has been many a time seen that after acute rheu- 
matism the only change discoverable in the heart may be 
a simple dilatation of the left ventricle — we must always be 
alive to the possibility of the existence of this condition, 
and take it into consideration in endeavoring to unravel 
the nature of individual cases of mitral incompetence. As 



69O DISEASES OF CHILDREN. 

already said, the heart probably dilates in childhood with 
undue readiness. It is this which constitutes the fatal 
element in so many cases of acute heart disease, and yet, if 
on the watch to avert it, and prompt to recognize it on its 
first occurrence, no doubt much may be done toward saving 
life, and sometimes toward restoring a heart to a normal 
condition, which, were it not for this, would pass on into 
incurable disease. 

Symptoms. — As regards symptoms, or the course of the 
disease, children are peculiar in one or two respects, which 
are worth noting. They emaciate more than is customary 
with adults, and the younger the child the more markedly 
is this the case. In very young children, the extreme 
emaciation and pallor of simple mitral regurgitation would 
often suggest a pulmonary rather than a cardiac affection, 
until auscultation reveals the true condition ; and it may be 
said, further, that physical examination reveals no other 
evidence of the cardiac affection than the murmur, disturbed 
cardiac action, and increased praecordial dullness. In young 
children, there is liable to be an absence of the hepatic 
enlargement which is common even in children a few years 
older — of seven, eight, or nine years. Heart disease in very 
young children — of one, two, or three years old — is a wast- 
ing disease. The reason for this is probably not far to 
seek : the cardiac defect at this time of life leads to impaired 
nutrition, as it does at any time ; but now it is vital, and 
rapid wasting results. The wasting so reduces the total 
blood supply that the circulation keeps within bounds, so to 
speak, and the mitral incompetence does not therefore pro- 
duce those extreme congestions of liver, spleen, and kidney 
which are the common features of a later age. For a 
similar reason, probably, severe cardiac dropsy is not com- 
mon in older children. We see a child with all the local 
evidence of an enormous heart and with a large pulsating 



DISEASES OF THE HEART. 69 1 

liver, perhaps without any ascites and generally without much 
anasarca, but such are always pale and always thin. Per- 
haps it is owing - to some explanation of this kind that chronic 
heart disease of children is in many cases amenable to treat- 
ment, as regards relief to urgent symptoms. The blood 
stream, diminishing, as it does, in proportion to the emacia- 
tion, is less likely to be dammed back irremediably in the 
lungs, and a temporary rest, with tonic and aperient medi- 
cine and careful feeding, certainly enables many a case of 
permanent mitral disease to go on for years.* It is difficult 
to prove, but the author has thought, after watching many 
of these cases for a long time, that here is the source of part of 
the number of cases of mitral stenosis that one meets with 
in adolescents and adults. May not the mitral regurgita- 
tion of infancy and early childhood, when recognized and 
carefully tended, be kept going until, in the natural order of 
things, the mitral inflammation — which at its outset pro- 
duced incompetence — contracts, and cicatrizes, so to speak, 
culminating in a cure in one sense — viz., a contraction of 
the orifice? The natural tendency of all inflammatory con- 
ditions of the mitral valve is toward constriction of the 
valve, but, like its parallel, urethral stricture, in the presence 
of an active dilating force — in the one case in the passage of 
urine, in the other, of blood by muscular propulsion — years 
pass by before any serious amount of disease is produced. 

As regards the symptoms of both endocarditits and peri- 
carditis, it must further be said, that in children of any age 
they are liable to be very obscure. A short, dry cough, 
breathlessness on exertion, and palpitation, may be all that 
have been noticed, combined with a gradual loss of flesh. 
But when examined, there may be the rounded chest, the 



* West gives several cases of the kind, and refers to a passage in Dr. 
Latham's book of similar purport. 



692 DISEASES OF CHILDREN. 

increased precordial dullness, the displaced, diffused, and 
heaving impulse, the roaring systolic bruit, which betoken 
not only old valvular disease but consecutive hypertrophy 
and dilatation also. 

Prognosis. — Acute peri- and endo-carditis, if they be 
attended with much turbulence and rapidity of action of the 
heart, or any evidence of consolidation of the lungs, require 
a guarded prognosis, based upon a careful study of the child 
and its surroundings. If, with the conditions just men- 
tioned, the child be restless, unable to lie down, takes food 
badly, sleeps badly, and, above all, vomits, the condition is 
one of great danger. At the same time, it is hardly possi- 
ble to avoid mistakes in forecasting the issue, seeing that 
some very bad cases rapidly improve, the consolidation of 
the lung and pleuritic effusion clearing up, and the heart's 
action quieting down ; while others no worse, perhaps not 
so bad as they, die off either quickly, or perhaps after 
hovering for some days without improvement. 

In chronic valvular disease, the opinion must be based 
upon the progress of the case. If the child takes food well, 
and the heart's action becomes quieter, the impulse less 
diffused, the separate sounds more distinct, and the con- 
gested viscera less hampered, while it is able to take the 
recumbent posture when asleep at night, further hopes may 
be entertained that it will ultimately reach a safe position — 
" safe but not sound," as Latham expresses it. 

In simple dilatation, the prognosis must also depend upon 
the extent of the dilatation and the evidence of impaired 
function which may be present. With close watching, the 
strictest rest, and the careful administration of digitalis and 
such like remedies, some of these cases unquestionably 
recover. 

Treatment. — The treatment presents no special features 
in children, but one may again insist that in acute cases 



DISEASES OF THE HEART. 693 

dilatation of the heart takes place with readiness, and this 
we must be on the watch to prevent or remedy. Opium is 
one of the most valuable remedies for this purpose, and 
with children of this age, six to fourteen, it may be used 
freely — three or four grains of Dover's powder every four 
hours may be given. Belladonna is useful, combined with 
bromide or iodide of potassium, according as there is need 
for soothing turbulent action, or for procuring the absorp- 
tion of inflammatory products. Then comes digitalis or the 
convallaria majalis, the former being much the more reliable 
in its action ; and last, but not least, stimulants, which are 
very necessary in some of these cases. Should there be 
much dropsy or scanty urine the tincture of strophanthus 
is a valuable remedy. A child of ten may have three or 
four ounces of wine a day, if by careful watching the con- 
ditions seem to improve under its use. If there be much 
pericarditis, counter-irritation to the praecordia may be kept 
up by a mustard-leaf or lin. iodi, and the chest wrapped 
round in a cotton-wool jacket. Absolute rest must be 
enforced for a long time, and, in the convalescing stage, 
iron and quinine should be administered for some weeks. 

Absolute rest must be continued for a long time. It may be 
well to emphasize this. There is no more important rule 
of practice, and none that is more often neglected. The 
case has been one of acute peri- and endo-carditis, and the 
heart is smothered in a thick jacket of lymph, its muscular 
wall is swollen and degenerated, its cavity in all probability 
dilated. The subject is a child of ten or twelve years of 
age. Is a two or three months' recumbency longer than is 
necessary under such circumstances for the repair of so 
damaged an organ? Is it too much to insist upon, when 
the future of a just-opening life depends upon it? The 
surgeon with the diseased joint makes light of a year of 
rest ; yet who has not seen a child after acute pericarditis 



694 DISEASES OF CHILDREN. 

skipping about at the end of a month or six weeks as if 
nothing had been amiss ? This ought not to be ; and in all 
cases, after rheumatic peri- and endo-carditis, the heart is 
to be rested in all possible ways for several months. There 
are many ways of accomplishing this ; but chief of all, natu- 
rally, is the avoidance of all bodily exertion. Where it is 
possible, no walking, not even feet to the ground, should 
be allowed for three months. The child is to be carried 
everywhere ; and when at last it is allowed to walk about, 
the pulse and heart's action should be carefully watched. 
We may remember, too, that the heart is rested also by 
sleep. As already remarked, the beats of the heart are 
sometimes considerably reduced in number at this time. 
It may be rested also by diet and general attention to 
bowels, etc. The food must never be allowed to overload 
the stomach, or stimulate the circulation too much. Rest 
is also to be obtained by tonics, which help the cardiac 
muscle to contract and slow the action of the heart. Here 
it is that iron acts — it restores the nutrition of the muscle, 
and thus slows the action. Digitalis, acting in another 
way, accomplishes the same purpose, and allows the heart 
more rest by prolonging the pause. Belladonna, convalla- 
ria, bromide of potassium, and hydrobromic acid are all use- 
ful, either in the same way or as sedatives in quieting the 
excessive action of the heart. 

Finally, as regards pericarditis, although purulent peri- 
carditis is by no means common, nevertheless, the student 
must remember that all serous inflammations in childhood 
have a greater tendency to the formation of pus 'than in 
adults. Therefore, supposing that in a case of pericarditis 
there is evidence of much effusion, and that evidence re- 
mains persistent — and still more so if the effusion has come 
on insidiously without any well-marked pericardial rub — 
the pericardial sac may possibly contain pus, and should it 



DISEASES OF THE HEART. 695 

do so, the question of its removal ought to be discussed. 
In such cases the child is very anaemic and very ill, and 
any treatment is only too likely to be ineffectual to avert a 
fatal result. Nevertheless, what little evidence there is 
points in favor of an exploration by a fine syringe, and, if 
pus should be found, of a free incision. Cases of this sort 
are no doubt very rare, and they usually pass away undiag- 
nosed (but this need not be). 

Paracentesis of the Pericardium. — Whenever an effu- 
sion into the pericardium, whether it be serum, pus, or blood, 
accumulates so rapidly or in such quantity that it threatens 
life, or where it refuses to undergo absorption by ordinary 
treatment, it is the duty of the attendant to tap the dis- 
tended sac. This rule holds good even though there be 
such constitutional disease present as must, in all probability, 
soon bring about a fatal termination. 

Aspiration is the method preferred to all others. It does 
away with the danger of suppuration, of hemorrhage from 
the wounding of any artery, and of fluid dribbling into the 
pleural sac, should it be punctured. The entire amount of 
the fluid can be withdrawn, and little injury will be done 
should the fine needle pass through the edge of the lung 
or strike the ventricular wall itself. Fitch's trocar, attached 
to Potain's aspirator with a vacuum-jar, should be used, the 
stopcock being turned to allow the atmospheric pressure to 
exert its force as soon as the trocar is buried beneath the 
integument. The operator is thus at once apprised of its 
entrance into the collection of fluid. 

The point of puncture preferred is the fifth intercostal 
space, close to and above the junction of the sixth rib with 
the corresponding cartilage. If there be evidence of point- 
ing, the tapping should be done at the most prominent 
point. Should the heart sounds be very loud at the point 
advocated for tapping, and adhesions be inferred, some other 



696 DISEASES OF CHILDREN. 

spot must be selected. In a monograph entitled " Para- 
centesis of the Pericardium," by John B. Roberts, m. d., 
from which this extract is taken, a table of sixty cases is 
given. Of these there were twenty-four recoveries and thirty- 
six deaths. Of those in the death column who survived 
the operation by a day, the average length of life was twenty- 
seven days. In other words, in those not already moribund, 
and who survived the shock of the operation, there was a 
probable prolongation of life of nearly four weeks. 

2. Malformations. — There are many varieties of malfor- 
mation of the heart, or, as it is generally called, congenital 
disease. There is patency of the foramen ovale, patency 
of the ductus arteriosus, deficiency of the septum of the 
ventricles, and stenosis of the aorta where the ductus arteri- 
osus opens into it, just beyond the left subclavian artery. 
There are other anomalies, such as a single ventricle arid 
auricle, one ventricle to the two auricles, or the viscera are 
transposed, the heart being placed on the right side of the 
chest and the liver and spleen transposing in correspondence, 
and, lastly, there are the various forms of adhesion and 
stenosis of the valvular orifices, chiefly of the pulmonary 
artery and of the aorta, and occasionally of the tricuspid 
and mitral also. But to give such a list as this is only to 
name the chief conditions. It will be quite unnecessary, 
however, to describe all these seriatim. Those malfor- 
mations consisting of reduction in the number of the cavities, 
are very rare, and generally destroy life quickly ; the only 
one, practically, which is in any way common — and this, of 
course, not so in the sense that its occurrence bears any 
proportion to that of other diseases of the heart — is stenosis 
of the pulmonary artery, with which is usually combined a 
deficient septum between the ventricles. Next after these 
in frequency comes a patent foramen oval and patent ductus 
arteriosus. And all these, while they may, and frequently 



MALFORMATIONS OF THE HEART. 697 

do, occur independently, more often are found in com- 
pany. 

Malformations of the heart vary with, and are in great mea- 
sure to be explained by a knowledge of, the stages of devel- 
opment of the fcetal circulation. In the earliest embryonic 
days the heart has no separate cavities ; it subsequently 
divides into two, and later into the four of the mature foetus. 
So with malformations ; do they occur early, we meet with 
one auricle and ventricle, the pulmonary and systemic ves- 
sels coming off from the ventricle in common. A little later, 
and there is the heart of three cavities, two auricles and a 
ventricle. Gradually, as the imperfections of later develop- 
ment remain persistent, so there is found a heart with four 
cavities more or less complete, usually with some deficiency 
in the septum, if not of the auricle, still of the ventricle. 
Now it is that the main vessels go wrong ; the pulmonary 
artery fails to develop, or its valves form a perforated cupola, 
or the conus arteriosus becomes contracted ; the blood under 
these circumstances cannot pass easily to the ductus arteri- 
osus by means of the pulmonary artery, and the more ready 
route, by the interventricular septum, is kept open, the pul- 
monary artery contracts, and the aorta becomes twisted 
toward the right ventricle. This is by far the commonest 
malformation — the pulmonary artery contracted, the inter- 
ventricular septum open, and the aorta, arising, as it is said, 
either from the right ventricle or from both — and it is at 
once apparent why it should be so common ; for, in addi- 
tion to the complex process which necessarily takes place 
in the accurate adjustment of the valves and in the forma- 
tion of the vessels from the branchial arches, it is brought 
about by other conditions which interfere with the natural 
flow of the circulation at that time of life. For example, 
a premature closure of the ductus arteriosus will so ob- 
struct the circulation along the pulmonary artery, that the 



698 DISEASES OF CHILDREN. 

blood will tend, as in the contractions at the ostium, to 
find a more ready outlet by means of a still imperfect 
septum. The premature closure or permanent patency of 
the foramen ovale or ductus arteriosus are usually among 
the malformations occurring during the later periods of 
foetal life. These are, perhaps, less easy of explanation — 
the former particularly so.' Of permanent patency it may 
be said, in the words of the late Dr. Peacock, whose mas- 
terly thoroughness has well-nigh exhausted his subject, 
" Under all circumstances it is very generally associated 
with some obstruction at or near the pulmonic orifice." 

To make the subject, however, more clear, let us with 
Peacock turn it round and trace the condition of the heart 
from the more perfect to the rudimentary forms. He 
says :* — 

" If, during foetal life, after the septum of the ventricles 
has been completely formed, the pulmonic orifice should 
become the seat of disease, rendering it incapable of trans- 
mitting the increased current of blood required to circulate 
through the lungs after birth, the foramen ovale maybe pre- 
vented closing; and, if the obstruction take place at an 
earlier period, when the septum cordis is incomplete, a 
communication may be maintained between the two ven- 
tricles. The same cause may also determine the permanent 
patency of the ductus arteriosus ; for if, during foetal life, the 
pulmonary artery be much contracted or wholly obliterated, 
the blood must be transmitted to the lungs through the 
aorta; and, unless the ductus arteriosus be itself obstructed, 
that vessel will necessarily become the channel by which it 
is conveyed. Similar effects would result from obstruction 
in the course of the pulmonary artery or in the lungs, in the 
right ventricle, or at the right auriculo-ventricular aperture. 

*" On Malformation of the Human Heart," pp. 159, 160. 



MALFORMATIONS OF THE HEART. 699 

So, also, obstruction at the left side of the heart, as at the 
left auriculo-ventricular aperture, or at the orifice or upper 
part of the aorta, would cause the current of blood to flow 
from the left auricle or ventricle into the right cavities, and 
thence, through the pulmonary artery and ductus arteriosus, 
into the aorta, and would equally determine the persistence 
of the foramen and duct or of an opening in the ventricular 
septum. The pulmonary artery and aorta would indeed 
appear to be either capable of maintaining for a time both 
the pulmonic and systemic circulations; and the necessary 
effect of the one vessel having the twofold function to per- 
form would be to give rise to hypertrophy and dilatation of 
the cavities of the heart more directly connected with it, 
and to the atrophy and contraction of those which are 
thrown out of the course of the circulation. 

" These effects of obstruction at the different apertures 
must vary, according to the period of fcetal life at which the 
impediment occurs. If the pulmonary artery be obstructed 
before the complete division of the ventricles, the aorta may 
be connected with the right ventricle, and both the systemic 
and pulmonic circulation maybe chiefly maintained by that 
cavity. If, on the other hand, the obstruction take place 
after the completion of the septum, the double circulation 
will be carried on by the left ventricle — in the former case 
the left ventricle, in the latter the right, becoming atrophied. 
The degree of obstruction may also influence the course of 
the circulation, and so affect the development of the heart. 
A slight impediment at or near the pulmonic orifice, while 
the growth of the septum cordis is in progress, will proba- 
bly give rise to hypertrophy and dilatation of the right ven- 
tricle, and to the persistence of a small inter-ventricular 
communication. More aggravated obstruction, on the con- 
trary, may arrest the progress of development, and throw 
the maintenance of the circulation on the left ventricle. The 



700 DISEASES OF CHILDREN. 

influence of obstruction at or near the pulmonic orifice or in 
some other portion of the heart, in modifying or arresting 
the development of the organ, is thus far capable of demon- 
stration; but it is probable that similar causes may equally 
give rise to the more extreme degrees of malformation, in 
which one or other cavity retains its primitive undivided 
condition. For if obstruction taking place during the 
growth of the septum be capable of preventing its complete 
development, it may be inferred that impediments occurring 
at a still earlier period may entirely arrest the formation of 
the septa, so as to cause the ventricle, or auricle, or both, 
to remain single, or to present only very rudimentary par- 
titions. It cannot, indeed, be disputed that in some cases, 
more particularly when the arrest of development is extreme, 
no source of obstruction exists to which the defect can be 
assigned ; but it must be borne in mind that the absence of 
any obvious impediment to the circulation, after a lapse of 
a considerable period, as in persons dying several years after 
birth, does not afford any proof that some obstruction may 
not have existed when the deviation from the natural con- 
formation first commenced. On the contrary, as remarked 
by Dr. Chevers, the condition which at first sight appears 
least in accordance with the theory of obstruction — that in 
which the pulmonary orifice and artery are dilated — really 
affords evidence that some serious impediment must have 
existed in the lungs or elsewhere, though it may have 
entirely disappeared." 

There are yet other malformations to be considered, not, 
however, of so much importance as diseases incidental to 
childhood, as for the questions they raise as regards the 
etiology of valvular disease, and they are, therefore, only 
mentioned to awaken interest and watchfulness for their 
detection. The first and more important is slight congenital 
defect in the various valves, which, by making them work 



MALFORMATIONS OF THE HEART. 701 

at a disadvantage, or inefficiently under increased strain, 
becomes an important source of disease in later life. Pea- 
cock was a strenuous advocate for disease having this origin, 
and his reasoning was based upon a very full inquiry into 
the facts for himself, and a perusal of published cases. There 
is no doubt much to be said in its favor. Some intra-uterine 
endocarditis occurs, and slightly thickens one or other of the 
valves. Adhesion between the flaps or cusps is thus pro- 
duced, and in the ordinary course of wear and tear such 
defects become suddenly accentuated, and disease gradu- 
ally progresses as the subject advances in years. There 
can be no doubt of the occasional existence of malforma- 
tions, which, though slight, are sufficient to lay the train 
of permanent disease, and to this extent it must be allowed 
that an argument exists for the occasional occurrence of 
mitral stenosis of a congenital form. At the same time, it 
must be said that on the left side this condition is very 
uncommon, and on either side, in proportion as changes — 
other than the perfect fusion of the valves, chiefly of the 
pulmonary and aortic valves, in a dome-shaped cupola, 
which all allow to be of congenital origin — are called con- 
genital, so it becomes difficult to be positive concerning the 
time at which they occur, mainly because a careful exami- 
nation of acquired valvular disease, rheumatic and other, 
aortic or mitral, shows that adhesion of the valves, matting, 
and the more moderate degrees of fusion, can be traced in 
all stages as the result of endocarditis of extra-uterine life. 
So much, indeed, is this the case, that it is very difficult to 
say what is certainly congenital. Nevertheless, the student 
should bear this question in mind, and endeavor, not only to 
satisfy himself on the matter, but, if possible, elucidate it by 
careful examination of such cases of endocarditis in very 
early life as come before him. 

The author can only allude to one other condition — viz., 

59 



702 DISEASES OF CHILDREN. 

the contraction of the aorta beyond the left subclavian 
artery. The aorta at this spot is more or less constricted, 
as if a string had been tied around it. Sometimes it is com- 
pletely obliterated at this spot. The ductus arteriosus is 
sometimes patent. The chief interest of the condition lies in 
bearing it in remembrance and correctly diagnosing it. It 
is compatible with many years of existence. In the two 
cases which have come under the author's own notice, one 
was a man, aged twenty-seven, the other, a man of thirty- 
seven years. It almost necessarily leads to hypertrophy 
of the left heart, and very probably to dilatation also ; while, 
from the fact that the circulation has to be carried to the 
lower part of the trunk by the subclavian and other vessels 
at the root of the neck, the enlargement of the surface 
vessels may allow it to be recognized. Goodhart believes 
that he has once recognized it in this way in the case of a 
man in whom, with obscure cardiac symptoms, some large 
arteries could be traced coursing beneath the skin in the 
scapular region. 

Symptoms. — The general symptoms of malformation of 
the heart are cyanosis, palpitation, and more or less impedi- 
ment to the respiration ; and they are generally present from 
birth onward. But they may be altogether absent ; they 
may occur only in paroxysms, or they may be absent for 
some time, even years, and come on without any assignable 
reason as the child grows older. Such children are, how- 
ever, usually ailing from birth ; they are easily chilled, and 
subject to attacks of bronchitis. 

As regards the local symptoms, bruits, etc., by which the 
particular malformation may be recognized, it can hardly be 
said that any are diagnostic. There may be no murmur 
even though the cyanosis is extreme, and when a bruit does 
exist, it is often so loud and harsh over the entire praecordia, 
that it is a matter of the greatest difficulty to localize it 



MALFORMATIONS OF THE HEART. 703 

definitely. Goodhart, in looking over fourteen cases, finds 
that two are cases of transposition of the heart ; one of the 
heart only ; a second of the heart and viscera. In both 
these a systolic bruit existed in the precordial region, and 
to the right side, which is not unlikely to have been de- 
veloped in connection with disease of the pulmonary 
artery. In five others the bruit was pulmonary or septal in 
position. In five there was an apex bruit, one accompanied 
by a thrill, and in which it was hardly possible to arrive at 
any positive conclusion ; in one, with much cyanosis and 
disturbed action, there was no bruit at all. In one there 
was a persistent humming-top bruit, which suggested a 
patent ductus arteriosus; and in one a loud systolic bruit, 
to the right of the spine more particularly, the nature of 
which was uncertain. 

The chief point to remember is that by far the larger pro- 
portion of cases are contracted conditions of the pulmonary 
artery, combined with a patent septum ventriculorum ; and, 
consequently, whatever the variations which the precordial 
bruit may present, unless other indications allow of its ex- 
clusion, this malformation is in all probability present. Its 
proper characteristics, however, are a systolic bruit along the 
left border of the sternum from third to fifth rib ; most in- 
tense in the mammary line, and running upward to the left 
clavicle, but not along the aorta or toward the axilla. There 
may sometimes be a thrill over some part of the area occu- 
pied by the bruit. The precordial dullness is usually ex- 
tended laterally to the right, by reason of the dilatation of 
the right side. A patent foramen ovale, although occasion- 
ally associated with cyanosis without other malformation, 
has so frequently been found without symptoms of any kind, 
that it can be seldom diagnosed. 

A patent ductus arteriosus can be but rarely capable of 
recognition. Walshe, from two published cases, thinks it 



704 DISEASES OF CHILDREN. 

" a matter of fair conjecture, that if a cyanotic adult (for 
which in this case we must read child) presented the signs 
of hypertrophy of the right heart, a negation of murmur at 
either apex of the heart, a single prolonged diastolic, or a 
double murmur, of maximum force at the pulmonary carti- 
lage, and not conducted downward, the cause of these com- 
bined conditions would be found in a patent state of the 
ductus arteriosus." The author ventures to doubt even so 
cautious a conclusion as this, because, from a case which 
has lately been under his observation, it is certain that a 
dilated pulmonary artery is by itself a sufficient cause of a 
bruit of this kind ; and both in Fagge's case, and that of 
Jaksch, from which Walshe draws his conclusion, the pul- 
monary artery was dilated. In the particular case he refers 
to, and which came frequently under his notice, the pecu- 
liarity of the bruit (it was delayed systolic rather than di- 
astolic, although it continued on beyond the systole into the 
diastole) consisted in its time and in a peculiar musical 
tone, and he went so far as to discuss not only the question 
of a patent ductus but also that of a communication between 
the aorta and pulmonary artery, as the result of aneurism, 
and also of simple aortic aneurism. All of these seemed 
possible. A mere dilatation of the pulmonary artery had 
not occurred to him, but such the post-mortem proved the 
condition to be. 

Now this may at first sight appear to be beside the ques- 
tion of congenital disease, because it is hardly a point which 
concerns the diseases of childhood ; a patent ductus being a 
recognized condition, a simple dilatation of the pulmonary 
artery hardly so. But a little reflection will convince one 
that this view is a narrow one. It has always been a ques- 
tion of interest to those who have made a study of the dis- 
eases of the heart and lungs how far collapse of the lungs in 
early infancy and childhood may be conducive to actual dis- 



MALFORMATIONS OF THE HEART. 705 

ease, and it is obvious that in atelectasis there is a sufficient 
cause, not only of dilatation of the pulmonary artery, but of 
patency of the ductus, dilatation of the right side of the heart, 
and patency of the foramen ovale, did it but occur a little 
prior to the time at which closure takes place in these aper- 
tures of communication between the two sides of the heart. 
We have, however, in atelectasis a cause of chronic valvular 
disease, if not of actual malformation, on the right side, 
which is probably of far more importance than that usually 
ascribed to it ; and for this reason the physical signs of dila- 
tation of the pulmonary artery are well worth the attention 
of the student. 

Simple stenosis of the aorta may be easily recognized by 
a loud systolic bruit along the aorta, by a systolic thrill, and 
by a slow pulse. It is not a condition which comes often 
under notice in childhood. It would appear that, if it be 
congenital, the disease goes on for a long time, the left ven- 
tricle undergoing hypertrophy, and compensation being 
complete. After a time, however, at two or three and 
twenty years of age, dilatation begins, and then it is that 
these cases come for treatment. 

Prognosis. — What is the duration of life in these cases is 
another question, which can only be answered in the most 
general terms. As a rule, all serious malformations cut life 
short early. The slighter forms, such as slight apertures in 
the foramen ovale or in the septum, are compatible, at any 
rate, with many years of existence. The risk to life is natu- 
rally in proportion to the derangement of the circulation ; 
and according to Peacock, the commoner forms of malfor- 
mation rank in order as follows, commencing with the least 
dangerous : — 

Moderate contraction of the pulmonary artery. 
Contraction of pulmonary artery and patent foramen 
ovale. 



206 DISEASES OF CHILDREN. 

Contraction of the pulmonary artery, with imperfect 

septum. 
Completely impervious pulmonary artery. 
A single ventricle to one or two auricles. 

While, however, all these bring life to a standstill within 
a few weeks or months in the great majority of cases, and 
those at the bottom of the list more speedily than those at 
the top, nevertheless there is no one of them which is not 
compatible with a life of many years. Therefore, for indi- 
viduals, the prognosis must be somewhat guarded. 

The causes of death are usually cerebral disturbance due 
to cyanosis, or imperfect expansion and collapse of the lungs, 
with some intercurrent bronchitis. 

Treatment. — This resolves itself into a few common-sense 
rules, which any one can suggest to himself. These chil- 
dren suffer from cold ; they must, therefore, be well clothed, 
and in cold weather be kept as much as possible in one 
uniform temperature. This is the more necessary, as the 
lungs are in a permanent state of engorgement and very 
liable to bronchitis, and sudden changes of temperature 
increase the risk. An attack of bronchial catarrh in any 
case of this kind may prove the last straw which brings the 
laboring circulation to a stop. Children with congenital 
heart disease are not uncommonly subject to outbursts of 
passion ; these must be guarded against as much as possible. 
The diet must be carefully regulated down to simples in 
small quantities, at somewhat more frequent intervals than 
is the usual habit of children : and if the emaciation makes 
way, they must be fed with tonics, cod-liver oil, and malt- 
ine. 

3. Cyanosis. — Two views have been held as to the 
cause of the extreme lividity that is so common a feature 
of congenital disease — one that it is due to the mixture of 
arterial and venous blood in the course of the circulation ; 



ANEURISM. 707 

the other that it is dependent upon the congestion which 
follows upon the obstruction of the pulmonary circulation. 
Of these two, the latter is without doubt the more generally 
correct, for these reasons chiefly, that it is not uncommon 
to find extreme cases of malformation with no cyanosis, or 
which are cyanotic only in paroxysms ; and also that simple 
pulmonary disease has been known to cause as extreme 
cyanosis as any malformation of the heart ever does, and 
that without any abnormal communication between the two 
sides of the heart. It is now, therefore, very usually taught 
that the cyanosis is due to the extreme obstruction in the 
lungs, and the consequent retardation of venous blood in 
the cutaneous capillaries. But this is not the whole truth, 
for such a discoloration as is met with from congenital heart 
disease is very uncommon from any other cause. It is 
therefore probable that the dilatation of the cutaneous 
capillaries most commonly reaches a sufficient pitch only 
when the disease takes effect in earliest infancy ; and it is 
not unlikely, also, that a certain thinning or delicacy of the 
skin is requisite to its full exhibition. Certain it is that, 
where the cyanosis is well marked, the skin is of a remark- 
ably silky, almost greasy, softness. 

4. Aneurism is not a common disease in childhood ; but 
when it occurs, and it may do so even in any of the larger 
vessels, such as the carotid, or iliacs, or femorals, it is almost 
always associated with (many think due to) the plugging of 
the vessel from an embolus, dislodged from the valves of 
the heart and carried to the diseased spot. The history of 
such a case is probably this : an inflammatory clot from the 
valves is dislodged and catches across the fork of a vessel, 
leads to clotting there, and then to inflammation of the 
coats of the artery ; the artery thereupon softens and allows 
of dilatation, under the pressure of the blood behind the 
plug, and an aneurism is formed. There is some doubt 



708 DISEASES OF CHILDREN. 

among pathologists about the exact mode of production 
of the aneurism, but of the fact, and of its association with 
embolism, there is no doubt. Aneurisms of this kind have 
been found in young people on the internal carotid, axillary, 
femoral, and popliteal vessels, not to mention the cerebral 
arteries, which have often been affected ; indeed, supposing 
that a young person should die with apoplexy, death is 
probably due to such an aneurism, which has ruptured after 
its formation. Occasionally, aneurism produced in this way 
has come under surgical treatment for the cure of the dis- 
ease ; but it is well to remember that the condition is an 
indication of the existence of the worst possible form of 
disease of the valves of the heart, one usually associated 
with embolism in many of the organs, and with hectic fever. 
It is nearly always fatal within a few weeks ; and there is 
hardly scope for treatment other than palliative. 



PART IX. 

DISEASES OF THE GENITO-URINARY 
ORGANS. 



The larger number of diseases of this class the physician 
is not called upon to treat. The majority of malformations 
of bladder and external organs, stone in the bladder, bala- 
nitis, phimosis, hydrocele, etc., fall entirely into the hands 
of the surgeon. Of these it is only necessary to say so 
much as concerns us ; but others have a more entirety 
medical aspect. To begin with, it may be well to remark 
briefly upon some of the not infrequent morbid conditions 
of the urine in childhood. They are but symptoms, it is 
true ; but their consideration as definite conditions saves 
both time and repetition. 

i. Hsematuria occurs under a variety of conditions, as 
the result of purpura, of scrofulous disease of the kidney 
or bladder, of calculus either renal or vesical ; it is not 
uncommon as the result of small growths about the urethra 
of the female child, and may, of course, be present as the 
result of nephritis, of renal tumor, or of cystitis. But 
besides all these, and more puzzling than they, children are 
brought to the out-patient room with a history of frequent 
passage of blood in the urine. Perhaps they are admitted, 
and the blood present once or twice within the first few 
hours disappears altogether, and does not reappear. It is 
difficult to say whence the blood comes in these cases. In 
60 709 



7IO DISEASES OF CHILDREN. 

some it may be derived from the kidney, in association with 
the presence of uric or oxalic acid in excess in the urine ; 
in some, perhaps, it is vesical, in association with the local 
congestion and irritation of ascarides ; possibly some may 
be cases of hemoglobinuria, of which the author has lately 
had an example in the case of a little girl in hospital. All 
these things would disappear under the warmth, careful 
feeding, and mildly laxative regimen of a hospital. At any 
rate, nothing more positive can be said for the guidance of 
the student. The blood is sometimes passed in large 
quantity in these cases, the urine being port-wine-colored 
and full of blood; and the feature of the case is, that it 
comes and goes quite suddenly, and there is no symptom 
of ill-health of any kind. There may be a little frequency 
of micturition, and on several occasions the child has been 
sounded for calculus on this account, but without the 
detection of any cause for the hemorrhage. The following 
case may serve to impress some of these points upon the 
reader : — 

A girl, aet. seven, was admitted into the Evelina Hospital 
with the history that she had been passing blood in her urine 
occasionally for four months. She was sent to the hospital 
by Mr. Duke. She had had scarlatina twelve months before. 
Four months before her mother first noticed that the urine 
was like dirty tea, thick, and — after standing — depositing a 
large quantity of red sediment. The child had never com- 
plained of any pain, and there had been no swelling of any 
part of the body, save that once or twice the mother thought 
that her child's eyes were rather puffy. For six weeks 
there had been blood in the urine. The. color of the blood 
was natural, well mixed with the urine, but there were some 
clots also. When she was admitted, Goodhart remarked 
that some of the features were those of vesical growth, but 
that it was a frequent hospital experience that children, with 



ANURIA. 711 

prolonged haematuria outside, speedily got well inside the 
hospital. So it proved to be. The urine on admission con- 
tained a quantity of blood, well mixed with the urine when 
passed, and a microscopic specimen consisted in great mea- 
sure of blood corpuscles, sp. gr. 1024, albumen one-eighth, 
no casts of any description. The child was admitted on the 
8th of the month, and up to the 10th there was still much 
blood. On the 12th it was only indicated by the guaiacum 
test; on the 14th, more blood again; 15th, none; 16th, 
none; 18th, much, with a sediment of dark-brown grumous 
matter, a few granular casts, and much albumen, sp. gr. 102 1, 
the character of the urine being quite that of renal disease. 
From this date only a trace of blood appeared once, but 
albumen appeared twice. She left the hospital three weeks 
later, apparently quite well. The child was never ill, never 
in pain, save that once she had an attack of abdominal pain 
while in the hospital, which might, perhaps, have pointed 
toward a renal calculus. 

The indication is in all such cases to examine for all the 
diseases which are known to produce hematuria, particu- 
larly for nephritis, for calculus in the bladder, for ascarides 
with prolapsus ani in either sex, and for some vesical growth 
in the female. Failing to find any disease to which to at- 
tribute the symptoms, the child must be kept in bed and 
watched, some gentle aperient being given, and probably 
some alkaline diuretic, the diet being kept for a day or two 
to milk food or fish. If the bleeding be severe, it may be 
advisable to give a little gallic acid, some tincture of hama- 
melis, or possibly a little turpentine. 

2. Anuria, or temporary suppression of urine, is a fre- 
quent affection in infants, and sometimes seems to depend 
upon an excess of uric acid in the urine. It is a condition 
which lasts but a few hours at most, is generally evidenced 
by symptoms of pain or discomfort when micturition takes 



712 DISEASES OF CHILDREN. 

place, and the urine, when examined, is found to be con- 
centrated, highly acid, and to have deposited a copious 
sediment of urates or angular crystals of uric acid. 

The application of flannel cloths wrung out of hot water 
over the lower part of the abdomen, together with small 
doses of sweet spirits of nitre, usually relieves this condition 
quickly. The child should be kept in bed and upon a milk 
diet. 

3. Dysuria. — The infrequency of micturition of infants 
just mentioned is replaced by frequency and pain in older 
children. The characteristics of the urine are the same. 

Causes. — Errors in diet and gastro-intestinal derange- 
ments appear to be the chief causes of these complaints, and 
they are frequent during dentition ; but it is not improbable 
that, as West remarks, they are frequently part of a con- 
stitutional tendency, and are liable to occur in children of 
rheumatic or gouty extraction. They are usually tempo- 
rary ailments, but sometimes in children of six or eight 
years of age, the passage of lithates or lithic acid may be 
associated with evidences of more prolonged ill-health. 
This class of cases has already been alluded to under hepatic 
diseases, to which of right they more properly belong. 

Diagnosis. — Care must be taken to exclude scrofulous 
pyelitis, calculus, urethral growths, or rectal troubles. 

Treatment. — Any errors in diet are to be corrected. 
Probably the quantity of food should be lessened, and fish 
rather than meat be given for a few days. As a medicine, 
it is generally sufficient to give some one of the laxatives 
already recommended — citrate of magnesium, compound 
decoction of aloes, etc., or sulphate of magnesium. In such 
cases as seem to suffer from any prolonged ill-health, some 
dilute nitric or phosphoric acid, with the tincture of yellow 
bark, may be given with advantage. 

4. Polyuria, like hematuria, is in many cases difficult to 



PYURIA. 7 1 3 

substantiate. It is the complaint of many a mother as re- 
gards her child, but under hospital regimen it is the rarest 
thing possible. It may be occasionally due to saccharine 
diabetes. 

Not long ago, a girl, aet. seven, was admitted to the hos- 
pital, who was said to have passed as much as half a gallon 
of urine in one night, and who had had polyuria, thirst, and 
wasting for three months. She continued to emaciate, and 
died without any adequate cause being discovered at the 
autopsy ; but, while in the hospital, her urine was never 
abnormal in any way. 

5. Pyuria. — Pus in the urine may come from cystitis 
from any cause, from scrofulous disease of the kidney, its 
pelvis, or ureter, from stone in the kidney (and, of course, 
in the bladder), and from any vaginal or pudendal dis- 
charge. 

Spontaneous cystitis appears to be not so very uncommon, 
and for the most part is associated with some febrile dis- 
turbance, together with frequency and pain in micturition, 
while the urine contains pus. Gee* records a case in a 
child of nine months, in which micturition was painless and 
not more frequent than usual. In some of these cases it is 
probable that the cystitis originates in some vaginal dis- 
charge, and spreads backward. 

A girl, aet. four years, had suffered from vaginal discharge 
for four or five months. For a week before she was admit- 
ted, she had had frequent and straining micturition, and 
screamed when passing water. The urine was faintly alka- 
line, contained a small quantity of albumen, and a large 
deposit of flocculent pus. She was examined under chloro- 
form, and plenty of pus issued from the urethra, but no cause 

* " On some kinds of Albuminous and Purulent Urine in Children : " Brit. 
Med. Journ.," vol. II, 1883, p. 961. 



7 H DISEASES OF CHILDREN. 

for the cystitis could be discovered. She was treated with 
salicylic acid (five-grain doses every four hours), and the 
micturition quickly became less frequent, and the pus 
gradually disappeared from her urine. The duration of the 
illness was six weeks. 

Treatment. — For such cases as these the child must be 
restricted to milk foods, and salicylic acid may be adminis- 
tered internally. Gee recommends benzoate of ammonium 
and pareira brava. 

Pyuria of longer duration is more likely to be due to some 
scrofulous condition of the kidney (when perhaps it may be 
possible to distinguish some enlargement of the organ by 
palpation of the loin), or to stone. 

6. Scrofulous Kidney may be associated with pain in the 
loin, with frequency of micturition, and with a flocculent 
purulent sediment of pus in the urine, occasionally with a 
streak or two of blood ; but it is quite necessary to remem- 
ber that it may be present also without any characteristic 
symptoms. The usual course of these cases is, after com- 
mencing in the renal pyramids, to produce gradual erosion 
and excavation of the organ, and extension of the disease 
along the ureter to the bladder ; but in the male there are 
often separate centres of caseous disease in epididymis and 
prostate, and these parts should be examined in the hope of 
throwing some light upon the diagnosis. The disease is uni- 
lateral in the sense that one kidney is generally much more 
involved than the other, but it is seldom confined entirely 
to one organ in old standing cases. The kidney in the late 
stage is much enlarged. Patients with scrofulous kidney are 
subject to the risk of the outbreak of a general tuberculosis. 

Treatment. — In the early stage, every effort should be 
made to improve the child's health. There is plenty of clini- 
cal evidence to show that scrofulous disease of the urinary 
passages is often of very slow progress ; there is plenty of 



RENAL CALCULUS. 715 

evidence from the post-mortem room, in the existence of 
calcification and tough fibrous tissue, that the disease un- 
dergoes processes of repair, and often becomes encapsuled. 
Therefore, in the early stage, resort should be had to sea-air, 
pure air, good living — in the way of cream, cod-liver oil, and 
food. 

As drugs, chloride of calcium should be given internally, 
or, perhaps, iodoform, if it can be taken. In the advanced 
stage, where there is a permanent and profuse discharge of 
pus which nothing can control, much pain and distress 
from frequent micturition, and progressive anaemia, an ex- 
ploratory operation should be performed, and the kidney 
drained, and possibly, should it be necessary, subsequently 
removed. 

7. Renal Calculus is sometimes, though by no means 
necessarily, associated with definite colic and hematuria. 
Renal colic in children is represented by, or perhaps it 
should be said described by them as, an abdominal pain 
referred generally to the umbilicus or front of the abdomen. 
A simple chronic or intermittent pyuria, with some irrita- 
bility of the bladder, may be all that points to the existence 
of stone. Calculus in the kidney is not uncommon. It 
will not be always possible to make a diagnosis ; but by 
keeping the possibility of its presence in mind perhaps, 
after these few suggestions, a mistake may sometimes be 
avoided. 

Concretions in the kidneys occur in two forms : uric acid 
infarctions, and calculi varying in size from that of a pin's 
head to that of a cherry-stone. 

Uric acid infarctions are found in the kidneys of infants 
who die a few weeks after birth, and in those in whom the 
respiratory function has been imperfectly performed during 
life. On section the organs present a regular and well- 
marked orange streaking of the pyramids, due, as the 



7l6 DISEASES OF CHILDREN. 

microscope shows, to the deposition of reddish-yellow crys- 
tals of uric acid between the epithelial layers of the straight 
tubes. 

When an originally insufficient respiration becomes nor- 
mal, the urinary excretion is increased, the infarctions are 
washed out and may be found upon the diaper in the form 
of minute red particles. 

Calculi have for their starting-point portions of infarctions 
left behind in the kidney, or arise during the course of dis- 
eases in which the quantity of urine is diminished. Their 
presence in children of three or more years may be indicated 
by the appearance of minute granules in the urine, by strain- 
ing or pain in micturition, and sometimes even urethral 
spasm. Should the concretions be passed into and retained 
in the bladder, they increase gradually in size. When 
retained in the pelvis of the kidney they may give rise to 
suppurative pyelitis. 

Alkaline waters, a non-albuminous diet, and warm baths 
for stricture or pain, constitute the remedial measures. 

8. Acute Nephritis has already been sufficiently dealt 
with, as regards symptoms and treatment, under the head 
of scarlatinal dropsy. But it will be well here again to intro- 
duce the subject, if only to express the conviction which 
many now entertain, that there has been far too much dog- 
matism concerning the scarlatinal origin of all cases of 
nephritis. It has been the custom to inquire for a history 
of scarlatina in all cases of albuminuria, and, whether elicit- 
ing it or not, to assume that it must have preceded the dis- 
ease. But apart from all evidence of preexisting scarlatina, 
the burden of proof, as Gee remarks, lies upon him who 
affirms that such nephritis must needs be scarlatinal. Good- 
hart has seen so many cases in which it was impossible to 
obtain the least evidence of scarlatina, that he has long 
taught that a spontaneous nephritis is not uncommon in 



RENAL TUMORS. JlJ 

children of all ages ; and Gee has lately stated that this also 
is his belief, as it is also of Ashby. Gee, in his paper on 
this subject,* alludes to the fact that acute nephritis may be 
wholly latent, and that the nature of the disease will cer- 
tainly escape notice if the urine be not always examined as 
a matter of routine. There may be fever, vomiting, and 
even coma, and per contra, there need not be any fever or 
any dropsy. 

For the treatment of such cases the reader may refer 
to the paragraph relating to the treatment of scarlatinal 
dropsy. 

9. Chronic Bright's Disease in children presents the 
same pathological appearances and symptoms, and requires 
the same methods of treatment as in adults. 

10. Renal Tumors. — A tumor in the loin maybe due to 
hydronephrosis, a very rare condition in a child ; to a saccu- 
lated abscess in a scrofulous kidney ; to an abscess around 
the kidney, either connected with spinal disease, or of renal 
or peri-nephritic origin, or to a sarcomatous growth of the 
kidney. 

Of hydronephrosis, the following case is a good illustra- 
tion, as it is also of a perhaps unusually rapid formation of 
the tumor : — 

A boy, set. 6, was under the care of the late Mr. John and 
Mr. Herbert Burton, of Blackheath. Three weeks before 
Dr. Goodhart saw him he had had a severe attack of sick- 
ness, and his abdomen, which had always been of sufficient 
size to procure for him the nickname of " Falstaff," was 
noticed to be larger than usual. At this time he com- 
plained of sharp abdominal pains, but the vomiting did not 
recur. When first seen, the whole of the left side of the 
abdomen extending beyond the median line was occupied 

* Loc. cit. 



15 DISEASES OF CHILDREN. 

by a hard and apparently solid tumor. There was some 
fluid in the peritoneum. He had sharp pains in the abdo- 
men. The urine was healthy. The author saw him a fort- 
night later. He was a bright, healthy child, rather thin, of 
gouty parentage. The left side of the abdomen was occu- 
pied by a large, lobulated, elastic swelling, which extended 
from the loin over to the right of the umbilicus. There 
was a distinct thrill from back to front. The urine was 
limpid, and contained neither albumin, blood, nor uric acid. 

The history and physical signs all pointed to calculus 
and subsequent hydronephrosis. Opium had already been 
given regularly, and it was decided to continue this with 
belladonna for a few days longer, with the result that three 
days later there was a sudden increase in the quantity of 
urine passed (3 pints); the following day 3^ pints were 
passed ; the tumor entirely disappeared, and no further 
symptoms were noticed. 

The cystic collections of fluid which sometimes follow 
injuries to the kidney are interesting, and, in some respects, 
peculiar. Mr. Godlee has published three cases of this sort, 
and, in addition to two others seen some years ago at 
Guy's Hospital, the author has lately met with a similar 
one in the practice of Mr. Watson, of Rochester. A boy 
of eight, of healthy parentage, fell on his right side on 
August 31st. Eight days afterward he began to pass 
blood in his urine, and continued to do so for more than a 
fortnight. This gradually ceased, but the abdomen con- 
tinued to enlarge, and his size was so much increased that 
his waistcoat could not be buttoned. A large cyst of fluid 
occupied the right side of the abdomen ; after a time it 
gradually diminished, but when Dr. Goodhart saw him, 
three and a half months after the injury, there still remained 
what appeared to be a large flaccid cyst with fluid contents 
occupying the right loin and right hypogastric region. 



RENAL TUMORS. 719 

These cases, Dr. Goodhart says, are peculiar, because it 
is probable that they are due to circumscribed extravasation 
of urine; they nevertheless form slowly, without any great 
degree of injury to the general health, and without the pro- 
duction of any such destructive tissue changes as are well 
known to occur in extravasation of urine in its more com- 
mon seat. 

The scrofulous kidney has already been described, and 
there remain only peri-nephritic abscesses and new growths. 
As regards the former, the presumption is in favor of spinal 
disease, and a careful examination of the spine should be 
made to establish the presence or not of any local disease ; 
but it is not always so. Extensive collections of pus may 
form around the kidney, which, if opened and drained, are 
speedily cured. In such cases the tumor is deep-seated and 
immovable, often ill-defined, from the presence of the colon 
in front of it. There is generally a good deal of pain, and 
some rigidity or flexion of the hip from implication of the 
origin of the psoas muscles, or pressure upon nerves. The 
author has lately had a case of this kind in a child of about 
seven. Mr. Lucas explored, and then opened and drained, 
a large abscess, and the child was well within a week or 
two. In such cases, generally of doubtful nature at first, 
we must watch carefully for the formation of fluid, and — 
should evidence be found of its existence — explore with a 
fine aspirator, and act according to the result. If pus be 
present, an opening should be made in the lumbar region, 
and the abscess "drained. Perinephritic extravasation of 
urine, due to rupture of the kidney or ureter, will require, in 
all probability, surgical treatment of some kind, with a 
view to the removal of the fluid and the prevention of its 
re-accumulation; but it is to be noted that much uncertainty 
attaches to the exact seat of the accumulation, and that in 
some, at any rate, of these cases the tumor has caused but 
little constitutional' disturbance. 



720 DISEASES OF CHILDREN. 

ii. New Growths. — These are chiefly sarcomata. They 
are not very uncommon. Goodhart has seen eight cases. 
Like all tumors in early life they grow rapidly, and ulti- 
mately produce an enormous distention of the abdomen. 
They are at the onset, and remain for some time, unilateral, 
for which reason they are most favorable cases for opera- 
tion. But when they have been long in existence, and have 
attained a large size, secondary nodules maybe found in the 
other kidney or in the lungs, etc. They grow for some 
time without attracting much attention, for they are not 
associated with much wasting; they are unattended by 
pain, and they are not generally accompanied by haematuria. 
Thus it happens that not till the abdomen — and, therefore, 
the tumor — attains a large size, is the child brought for 
treatment. 

They occur in quite young children of eighteen months 
to three or four years old, when the removal of a mass so 
large is necessarily a most formidable operation. But, if 
they should be recognized sufficiently early, considering that 
they are usually local tumors and certain to prove fatal if 
let alone, then removal may be attempted. Of the six cases 
in the Evelina Hospital, four have come under the author's 
notice, and two under the care of his colleague. In one of 
his own the removal of a very large tumor was attempted by 
Mr. Howse in a boy of two years, and had to be abandoned, 
a result for which they were prepared ; in another case 
under Mr. Howse the tumor was removed, but the child died 
very soon after the operation, also a result for which one 
must be prepared if the operation is to be undertaken at all ; 
in a third case, after the most careful consideration of all the 
circumstances, it was decided to operate, and Mr. Symonds 
removed the tumor, but, though in this case not very large, 
it had already infiltrated the outer coat of the colon, and 
therefore, had the child recovered, little advantage would 
have been gained ; and in a fourth case, also under Mr. 



NOCTURNAL INCONTINENCE OF URINE. 72 1 

Howse, the tumor was removed, and the wound healed, but 
the child afterward died of measles. Of the other two, one 
died, after many weary months of gradual emaciation, and 
one still lives — the parents, with whom alone a decision so 
momentous must rest, being unable to decide whether they 
will risk an operation. 

12. Nocturnal Incontinence of Urine, or Enuresis. — 
There are few conditions which require more careful inves- 
tigation than this, and few in which such a variety of cir- 
cumstances may conspire to bring it about. Granting that 
it depends upon a nervous fault, the results of treatment 
would seem to show that sometimes it is due to hyper- 
sensitiveness of the centre, sometimes to deficiency of the 
natural delicacy of perception either on the part of the 
lumbar cord or the higher centres to which it should 
transmit its own knowledge. 

How many other considerations also does the disease 
entail ? In some cases the constitutional build of the 
patient must be considered ; the sleeping habits of the nerv- 
ous system ; the question of developing sexual sensation ; 
the condition of prepuce, urethra, rectum ; the possibility 
of the existence of local disease ; the presence of ascarides ; 
and, in confirmed cases, the question of habit. The mere 
mention of all these things will be sufficient to show that 
whoever will treat enuresis with success must be prepared 
for a preliminary inquiry of a somewhat complicated nature. 

After saying thus much, it will not be expected that the 
reader should be advised to hit out at random with bella- 
donna, or bromide of potassium, or chloral. Each case 
must be investigated carefully, and treated accordingly. If 
there be any phimosis, this must be attended to, not neces- 
sarily by an immediate circumcision, but at any rate by 
retraction, separation of any existing adhesions, and the 
removal of any retained secretion that may be present. 



722 DISEASES OF CHILDREN. 

Circumcision is a useful thing, if there be reason to suppose 
that the length of the prepuce or the tightness of the phi- 
mosis is a disposing cause. Local congestion, perhaps due 
to constipation or to the presence of worms, must be ex- 
amined for. In other cases the tone of the nervous system 
is at fault, and during the night there is a general or local 
erethism of the nervous centres which leads to this spas- 
modic discharge. This state of the nervous centres is 
sometimes constitutional and closely associated with rheu- 
matism. In this case it goes with, or is allied to, such ner- 
vous disorders as nightmare, somnambulism, possibly even 
epilepsy. In other cases this nervous erethism is dependent 
upon sensations which have their origin in the developing 
sexual centre, and unquestionably there is a form of nocturnal 
incontinence which replaces the seminal emissions of the 
mature organism. Allow this, and how complex the ques- 
tion becomes. Sometimes there is the low tone and in-bred 
sensation ; sometimes the sensations may be called into being 
by external circumstances, such as a too hot or too comfort- 
able bed ; sometimes, may be, there is some local peripheral 
excitement, a long prepuce, or an over-acid urine, for ex- 
ample. In some children, again, it seems that sleep is too 
sound, and secretion too rapid ; and the reflex centre, uncon- 
trolled, acts in accordance with its natural habit, and the urine 
is passed into the bed. 

Thus, in enuresis, very much the same questions come 
over again that have already been discussed in connection 
with the gastro-intestinal derangements of infants. A little 
physiological reflection, if it does not make the whole sub- 
ject clear, at any rate leaves one with the comfortable 
opinion that he knows something about it, and has definite 
aims in the treatment of a somewhat mixed class of cases. 

Of thirty-eight cases, twenty were girls and eighteen 
boys. The favorite age is about seven ; but twenty-seven 



ENURESIS. 723 

of the thirty-eight occurred from six to eleven years; seven 
others at three and four years of age. Eight occurred in 
rheumatic families. 

Treatment. — The treatment of these cases justifies all that 
has been said. There are some which are cured off-hand 
by bromide of potassium and hydrate of chloral, just as 
infantile convulsions and night terrors are almost certainly 
controlled ; there are others as certainly controlled by bel- 
ladonna, which not only heightens arterial tension and thus 
tends to restore the nervous tone, but also has some para- 
lyzing effect on the afferent nerves, while it is well known to 
control what is the allied condition of seminal emissions. 
For this latter remedial action Unna speaks highly of the 
liquid extract of rhus aromatica ; five drops three times a 
day for children under two years, ten drops to those between 
two and ten years, and fifteen to such as are older. There 
are other cases best treated by good nervine tonics, such as 
strychnia and dilute phosphoric acid. Others, those of heavy 
sleepers, must be less luxuriously housed. Others, again, 
of rheumatic tendency, may be passing a highly acid urine, 
which irritates the bladder and provokes expulsion ; this may 
be remedied by cutting off all meat from the diet for a week 
or ten days, and adding some bicarbonate of potassium to 
the food. If the urine is turbid and alkaline, a condition 
which is quite as provoking to the bladder as an over-acid 
state, though not so frequently met with, dilute phosphoric 
acid and nux vomica or a little salicylate of soda should be 
given. In all cases a better habit should be favored, by 
restricting the quantity of drink toward the end of the day, 
and by arranging that the child be taken up to pass water 
late at night, early in the morning, and, if necessary, once 
during the night. In all cases the general health must be 
looked to, and tepid and cold bathing be practiced when 
possible. 



724 DISEASES OF CHILDREN. 

Occasionally, the incontinence is not only nocturnal but 
occurs during the day also. The affection is sometimes in 
such cases a part of an imbecile condition, and in rar.e cases 
the faeces are evacuated irregularly also. When daily as 
well as nightly, they are likely to be very intractable, and 
are cases for a very careful examination of the pelvic organs 
under ether. It may be that, by long persistence of the 
habit, the bladder has become so contracted as to be in- 
capable of holding any quantity of urine, and in such cases 
the author has once or twice found it necessary to distend 
the bladder by injecting water, under ether. 

In any case, long persistence in the habit will necessarily 
make the case obstinate. For our comfort we may remem- 
ber the usual doctrine, that such cases generally ameliorate 
at puberty ; but it may also be said that, in proportion as an 
early and intelligent appreciation of the problem is brought 
to bear upon an individual case, so is it likely to prove tract- 
able. Intractability is the recompense of an indolent and 
undiscriminating administration of belladonna or whatever 
comes to hand. 

Dr. Goodhart couples incontinence of urine in child- 
hood with chorea ; not at all because they are obstinate — 
though he does not deny that — but because the difficulties 
as regards treatment are seldom fairly grappled or placed 
before the parents. As one who, from the very nature of 
his practice, sees something of a side light of the relations 
existing in such cases between the medical man and his 
patient, Goodhart gives his experience as follows : — 

A child suffers from incontinence of urine ; for some time 
no medical advice is sought; when it is, belladonna is 
usually prescribed. The child is seen in a casual sort of 
way every few days ; there is a lingering medical attend- 
ance; and in the end very little, if any, improvement. Then 
comes a relapse from all treatment, and after a time " further 



ENURESIS. 725 

advice" is sought, in most cases without any intimation to 
the original attendant, and with a very strong disinclination 
on the part of the parents to return whence they came, 
because of their fruitless experience. Now, see what has 
happened ; an appetite for a " prescription" has been whetted ; 
the parents have been led to believe that some drug is the 
panacea, if only some one can be found with sufficient 
acumen or experience to recommend the right one. They 
have no insight or knowledge of disease as a habit which is 
only to be controlled by close medical supervision ; or if 
by drugs, by such as are potent, given with a free and 
therefore necessarily with a very watchful hand. Over and 
over again parents are found to grumble at the prospect of 
a lengthy medical attendance, a poor receipt, as they con- 
sider it, beside the three-ounce bottle of medicine, and a 
cure in its dregs, for which they thought to come. Now, the 
parents are in many cases not so much in fault as the 
doctor. This disease is too often treated with a non- 
chalance which conveys the idea that it is an inconvenience 
which must be put up with, if it is not cured offhand by so 
much belladonna. But is this so in fact ? Is it not much 
rather a malady productive of the greatest misery to the 
child, a great hindrance to his education ; a malady, in short, 
in which anything less than the exhaustion of every possible 
means of relief is a cruelty ? The worst cases are confess- 
edly troublesome, and if they are to be combated success- 
fully, the reason of their obstinacy must be explained to the 
parents at the onset. By so doing their intelligence will be 
enlisted in furthering the efforts of the doctor ; they will 
understand the reason and the necessity of a possibly 
arduous attendance ; they will be prepared for, not disap- 
pointed or not disheartened at, a possible failure ; and the 
utmost will be done to effect a speedy cure. 
61 



726 DISEASES OF CHILDREN. 

13. Calculus Vesicae only needs mention as a complaint 
of which the diagnosis frequently falls upon the physician. 
The author is under the impression that during the years 
that he saw out-patients at the Evelina Hospital, the 
majority of cases of calculus were sent into the hospital by 
him ; at any rate five such cases occurred. The symptoms 
are pain in micturition, frequent micturition, stoppage in the 
flow of urine, uneasy sensations after emptying the bladder 
— worse when moving about, the occasional presence of a 
little blood in the urine, of pus or mucus in excess more 
frequently, and incontinence of urine. 

Diagnosis. — Many conditions simulate stone — e. g. y rectal 
worry by worms or polypus ; penile worry — e. g., a long or 
adherent prepuce ; disease of the kidney or bladder, and, 
in the female, vaginal discharge, etc. 

14. Vaginal and Labial Discharges are due to some 
eczema of the external parts, or to some catarrhal state 
depending on the presence of worms, or to ill-health in 
scrofulous or tubercular children. 

Treatment. — At first this may be confined to plenty of 
bathing and to tonics, such as the lacto-phosphate of iron 
and cod-liver oil. If worms are present, they must be 
attacked by enemata or aperients. Later on, the vagina 
may be syringed with a lotion of lead or salicylic acid. 

15. Noma* is so rarely seen that it may go undescribed; 
it is noted by Dr. Marshall as not uncommon after measles. 

* Noma pudendorum. 



PART X. 
DISEASES OF THE SKIN. 



The skin diseases of children are so numerous, and the 
literature of dermatology is so extensive, that the subject 
does not readily lend itself to a manual which treats of gen- 
eral medicine. However, it will be necessary to refer shortly 
to those more common affections which are of every-day 
occurrence, and to some few of the rarer conditions. A 
fuller treatment of the subject will not be necessary, con- 
sidering the many excellent manuals that have been written 
of recent years. 

As a preliminary, let me say that perhaps there is no organ 
of greater importance than the skin in childhood. It is in 
many cases a most sensitive index of inefficient working 
elsewhere; its suggestions as to constitutional peculiarities 
are often of the utmost value to the physician ; when not 
properly cared for it readily goes wrong ; and rough hand- 
ling is quickly resented. Its very activity is a source of 
danger if it be neglected, and many of the diseases of the 
skin in infant life are directly chargeable to neglect. There- 
fore, as a general principle, it is of the first importance to 
attend to scrupulous cleanliness. A good bath once a day 
is not too much for any child, and a bath night and morning 
should be given to young children. Most children perspire 
readily and excessively, particularly during sleep, and re- 
tained perspiration about the neck or in the groin, etc.,pro- 

727 



728 DISEASES OF CHILDREN. 

duces first miliaria, and then intertrigo. Plenty of bathing 
and the use of the sanitary rose powder, in such parts as are 
liable to retain the secretions, will no doubt avert many a 
case of what would otherwise prove a troublesome eczema 
or intertrigo. 

Warmth is another essential. Custom has prescribed that 
young children shall wear low dresses, short sleeves, petti- 
coats, and no covering at all for the lower part of the abdo- 
men and thighs, save a pair of linen drawers. This is a 
custom framed upon a weakest-goes-to-the-wall principle, 
which is opposed to the very raison d'etre of medicine. 
Children's clothing is to be light and loose and warm. The 
method of accomplishment of these aims hardly needs a 
more detailed statement. 

The more common affections of the skin are : Lichen — 
often called strophulus or lichen urticatus, from its almost 
inseparable connection with urticaria — eczema, impetigo, 
ecthyma, furuncular eruptions, herpes of all patterns, ery- 
thema likewise, psoriasis, tinea, alopecia, and molluscum 
contagiosum. 

Of rarer occurrence are pemphigus, ichthyosis, lupus, 
keloid, erysipelas, scleroderma, xanthelasma, and favus. 

i. Lichen urticatus, or strophulus, the red gum and 
white gum sometimes talked of, occurs chiefly from the age 
of five or six months onward through the period of denti- 
tion. It is not unusual from two to four years, but its 
history may then be traced from a much earlier date ; and 
even in older children, of eight, nine, or ten, a persistent 
lichen urticatus is occasionally met with. As seen in infancy, 
it occurs as rather sharply raised, whitish, rounded papules 
of a peculiarly hard or shotty feel, and often with a trans- 
lucent centre, looking like a vesicle, but from which no fluid 
comes when pricked. The forearms, legs, and trunk are its 
favorite sites. It is very irritable, and associated often with 



STROPHULUS. 729 

urticarica, and for this reason the appearances vary, the 
characteristic papules becoming lost in wheals or changed 
into a number of bleeding or crusted points, from the 
excoriation produced by scratching. Closely allied to this 
disease and to urticaria is another, which has been called 
urticaria pigmentosa, or xanthelasmoidea, in which the 
trunk more particularly becomes covered with yellowish- 
brown blotches, the skin at the affected spot being raised 
and thick, like soft leather. Urticaria wheals are frequently 
seen about the body, and the history is often that the pig- 
mented thickenings have begun as such — a fact as to the 
truth of which the author has on more than one occasion 
satisfied himself. This disease was first described by Til- 
bury Fox as xanthelasmoidea, and a good many cases have 
since then been recorded. Dr. Colcott Fox has given a 
careful summary of all these,* and in addition has added 
important information on two points — first, he shows that 
the disease tends to disappear as the child grows up ; and 
secondly, that the microscopical structure of the affected 
tissue is that of a wheal. 

It is important to recognize in all these three affections 
that the difficulties of treatment lie less in the actual struc- 
tural changes in the skin than in the fact that all these chil- 
dren have what Hutchinson calls a pruriginous skin. The 
subjects of urticaria pigmentosa have not only a pruriginous 
skin, but, also, as some cases of pemphigus, a peculiar ten- 
dency to the deposition of pigment in the skin. It is the 
constitutional element, if it may be called so, which allows 
of lichen, while some slight disturbance is the immediate 
provocative. Most often this is gastric disturbance or indi- 
gestion during dentition ; sometimes it is the irritation of 
flea-bites ; sometimes, again, as Hutchinson suggests, a 

* " Trans. Med. Chir. Soc " vol. lxvi. 



730 DISEASES OF CHILDREN. 

varicella or some other exanthem. Hutchinson distin- 
guishes between a prurigo due to varicella and that due to 
other causes, by the former being vesicular, the latter not ; 
but this distinction is not of much service. Some exceed- 
ingly practical and valuable remarks, however, are made 
concerning the prpduction of a pruriginous skin by erup- 
tions of any chronicity, for all must be familiar with the fact 
that to scratch an itching spot is not only to make the spot 
more irritable, but also to extend the actual area from which 
the abnormal sensation is transmitted. It is easy thus to 
make the body itch all over ; and this condition begets a 
pruriginous habit of skin which is quite out of proportion 
to the external cause. 

Treatment. — Lichen urticatus is very obstinate. It and 
all three, affections in this group are for the most part best 
treated by the strictest attention to the diet ; but it is in 
many cases very difficult to say exactly in what element the 
cause of indigestion lies. Some children are said to be 
worse when eating sugar, some when they have taken too 
much milk ; but it is difficult to make dogmatic state- 
ments. 

Having already given full space to diet, it is only neces- 
sary to say that it will require careful scrutiny and probably 
modification according to the rules already detailed. Next in 
importance comes the necessity to deprive the surface as far 
as possible of all excuse for itching. This may be done both 
by external and internal means. Externally, the most scru- 
pulous attention is to be paid to cleanliness. The skin is to 
be bathed frequently ; the linen is to be changed frequently, 
to ensure the absence of such pests as fleas ; and in hospital 
out-patients, scabies and pediculi must be examined for and 
treated if present. The nature of the clothing next the 
skin must also be examined. Some people are unable to 
wear flannel, or particular kinds of flannel, merino, etc., and 



STROPHULUS. 731 

dyed flannels are sometimes in use which may account for 
external irritation. The itching of the papules may be 
mitigated by gently rubbing over them and the affected skin 
a lotion of bicarbonate of sodium, glycerine, and elder-flower 
or rose-water, or a lotion of corrosive sublimate ; half a 
grain to each ounce is sometimes effective. 

R . Sodii bicarb., 3 ij. 

Glycerinse, (%'). 

Aquae rosae, q. s. ad f 5VJ. M. 

Sig. — For a lotion. 

R. Hydrarg. perchlor., gr. iij. 

Chloroform., rr^xx. 

Glycerinae, f.^ij- 

Aquae rosae, q. s. ad f t ^ vj. M. 

Sig. — For a lotion. 

Borax and glycerine may be used for the same pur- 
pose, or the skin may be oiled with vaseline or carbolic 
oil (1 to 40). Hutchinson recommends a solution of the 
liquor carbonis detergens (one part to four or five of 
water). 

For the more chronic cases, a tar bath may be given, by 
adding the liquor carbonis detergens to water ; or sulphur 
baths are useful — a tablespoonful of sulphur, or more, to a 
bath. 

For internal administration in the acute stages, bicarbo- 
nate of sodium or potassium may be given, or some fluid 
magnesia. Either of the following formulas will answer the 
purpose : — 

R. Spt. aeth. nit., fgj. 

Magnesiisulpkat., :jj. 

Olei cajuput., mj. 

Syr.Tolu., f^ij. 

Liq. magnesii carb., fjij. M. 

Sig. — Teaspoonful 2 or 3 times a day. 



732 DISEASES OF CHILDREN. 

R. Sodii bicarb., ^j. 

Tr. nucis vomicae, ^V]- 

Tr. cardamom, comp., f ^ ij. 

Syrupi, f£ij- 

Aq. chloroform., f^ss. 

Aquae, q s. ad f^ij. M. 

Sig. — Teaspoonful every 6 hours. — (Eustace Smith.) 

For older children, quinine in full doses, or cod-liver oil, 
seems to be of most service. The confection of sulphur 
and euonymin are also of value in regulating the bowels 
and stimulating the liver. 

2. Acute Urticaria is far less common than the chronic 
conditions just described. It is readily recognized when the 
wheals are out, unless, as is sometimes the case, these are 
exchanged for a more or less general cedema, when the face 
becomes swollen, like the visage of a child with pertussis, 
and the subcutaneous tissues of the extremities are rendered 
somewhat brawny. When the wheals are not out, there 
may be also a difficulty, very little remaining but small 
red papules, with perhaps — when the itching has been 
severe — a subdued ecchymosis or dusky condition of the 
skin. 

Acute urticaria is certainly due immediately to errors in 
diet, though it is not unlikely that idiosyncrasy may be the 
remote cause. It is to be treated by attention to the diet, 
and usually some alkali. To allay the severe itching, 
bicarbonate of sodium, dissolved in equal parts of glycerine 
and water, or glycerine and rose-water, rubbed gently into 
the part, is one of the best remedies. Gentle friction with 
sweet oil is also useful ; and perhaps it is well to remark 
that whereas violent scratching increases the irritation, 
gentle rubbing is one of the best calmatives possible to a 
pruriginous skin. 

3. Eczema is most commonly seen about the head, ears, 



ECZEMA. 733 

and face, and in such other parts as are subject to chafing 
and to the irritation of excessive perspiration — in the creases 
of the neck, in the axillae, groins, scrotal and anal regions, and 
round the umbilicus. It may be hereditary, perhaps not as 
eczema from eczema, but from a rough or scurfy skin, or an 
abnormality of some sort. Like strophulus, it often owns 
an external cause which may be slight in comparison to the 
amount of the disease. In hospital out-patients it is often 
associated with scabies and pediculi — in both cases the erup- 
tion may be not only vesicular but pustular (eczema im- 
petigo). Eczema capitis is sometimes very chronic, and is 
one of the most obstinate affections of young children. 
Such cases sometimes remain for months in hospital and 
seem to derive no benefit from any remedy, notwithstanding 
that the child's general health improves or may even appear 
to be of the best. Eczema is a disease which has a distinct 
predilection for the first four or five months of life — twenty- 
five cases out of thirty-three, occurring in the first year of 
life, being under five months. Between one and two years 
the disease is common — ten cases in the thirty-six were over 
a year. From two to six years the disease is more evenly 
distributed, and after that it becomes uncommon. It is a 
disease which is often attributed to vaccination ; and I think 
it must be allow r ed that, although the charge is often a 
groundless one, nevertheless, in unhealthy children or those 
of pruriginous habit, it is a disease which is occasionally 
excited by the condition which vaccination engenders. It 
may equally originate in a varicella, or after measles or any 
other exanthem. 

Treatment. — This must be general and local in acute 
eczema. In the main, it requires careful dieting, abstinence 
from starch and saccharine matters, and the internal admin- 
istration of bicarbonate of sodium or potassium and nux 
vomica. A powder of bicarbonate of sodium (gr. v.) and 
62 



734 DISEASES OF CHILDREN. 

sulphur (gr. v.) is a useful combination, and may be readily 
given in milk three or four times a day. Small doses of the 
tincture of rhubarb, the tincture of podophyllin, or of aloes, 
or of euonymin, may also be of service. A little hyd. c. 
cret. seems also to be useful in some cases ; and all these 
children are the better for a tonic of tartrate of iron after the 
rash has disappeared. When there is much itching, a dose 
of chloral may be given internally, either at bedtime or 
occasionally repeated during the day; and Dr. Pye Smith 
speaks highly, from his own experience, and that also of 
Dr. Fagge and Dr. Eustace Smith, of the value of quinine 
in such cases. It is given as a single dose of half a grain, 
or a grain or more, according to the age of the child, an 
hour before bedtime. 

For local applications, quite a number of thinge are use- 
ful at one time or another. In very acute cases, soothing 
applications, such as lead lotion, will be required tempo- 
rarily ; but more generally the ung. metallorum (equal parts 
of the zinc, nitrate of mercury, and acetate of lead oint- 
ments) or some preparation of zinc. The zinc ointment is 
too thick ; it may be made fluid by the addition of olive oil, 
or made with vaseline in place of the benzoated lard, or 
the oxide of zinc may be lightly dusted over the affected 
parts, after they have been freely smeared with olive oil. 
The glycerinum boracis is useful at times ; and for parts 
which require to be dried in some measure, the oleate of 
zinc, scented with thymol (Martindale), or the sanitary rose 
powder, is a useful preparation. 

In the more chronic and drier forms, arsenic and cod- 
liver oil are of most use internally ; and as local applica- 
tions, creasote ointment, or an application of the oil of cade 
one part, and vaseline four parts, or of any strength that 
may be deemed necessary. 

For chronic eczema of the scalp, the local application of 



IMPETIGO. 735 

cod-liver oil is sometimes of use, in addition to the internal 
administration of the drug. But these are cases which 
require the utmost patience and perseverance. 

In the eczema impetiginodes of the scalp, all that is 
usually necessary is to see to the destruction of all pediculi, 
the removal of all dry crusts, by softening them with oil 
and poultices, and the application of the ung. metallorum. 

In the patches of eczema so common about the face, a 
little unguentum metallorum is the best remedy. 

For intertrigo, the parts should be bathed two or three 
times a day, dried carefully with a soft towel, and then 
dusted over with sanitary rose powder or oleate of zinc, 
above mentioned. Should these fail, one or other of 
the applications already mentioned may be tried. The 
parts should be covered up as little as possible. Soap 
should be avoided in eczema, except in very chronic cases, 
the bath being one of warm water, with some fine oatmeal 
added. 

Children with a tendency to eczema require attention to 
their food and occasional tonics, more particularly for some 
few weeks after an attack — a few drops of cod-liver oil twice 
or three times a day, or the lacto-phosphate of lime and 
iron, combined with a little arsenic. 

4. Impetigo is most common on the scalp, where it is 
very generally associated with pediculi. If the disease is 
extensive, it is better to remove the hair as closely as pos- 
sible, apply poultices and oil to remove the crust, and sub- 
sequently some unguentum metallorum to the pustular 
sores, and a weak carbolic oil to the rest of "the scalp. 
When the sores have healed up, then come free washings 
with soap and water, and perhaps some ammoniated mercury 
ointment (gr. v. to the ounce of vaseline), to get rid of the 
pediculi. Impetigo may occur on other parts of the body 
as scattered pustules. These usually indicate that the child 



73^ DISEASES OF CHILDREN. 

is out of health, that it is fed too well or too ill, or wants 
change of air or tonics. This complaint, like eczema, is 
liable to be set up by and mask scabies. 

Impetigo contagiosa has been described as a special form 
which occurs in epidemics, runs through a household, and 
is preceded by febrile disturbance ; it is distinguished, in 
short, by the characteristics of an exanthem. Goodhart 
has seen several children suffering from impetigo in one 
house. Tilbury Fox states that he has " again and again 
reproduced the disease in others by inoculation." The 
nature of the disease is still obscure. It is said by Fox to 
begin as a vesicular disease, and thus to differ from other 
forms of impetigo, and also from pustular scabies, with 
which it may be confounded. It seems possible that it 
might also be mistaken for varicella. 

Treatment. — The contents of the pustules being inocu- 
lable, care must be taken to prevent the pustules being 
scratched, and to render the pus harmless. This is best 
done, according to the author quoted, by an ointment of 
ammoniated mercury. Some tonic medicine will in all 
probability be advisable as well. 

5. Ecthyma occurs in unhealthy children, who usually 
require tonics and cod-liver oil. The crusts which form on 
the sites of the bullae of pemphigus may look like ecthyma 
in some instances, and the fact should be remembered. The 
unguentum metallorum is a good local application. 

6. Furunculi, or boils, are common at all ages, but they 
are chiefly met with in young children from one to three 
years, and in boys of eight to ten or twelve. In the younger 
subjects they are more prone to appear as red, brawny in- 
durations, hardly to come to a head, and they run a rather 
slow course. Boils are often exceedingly troublesome — 
not so much in the cure of any one, although this is no light 
matter, for the pain and depression caused is quite out of 



furunculi. 737 

proportion to the size of the local malady — but in the fact 
that certain individuals are subject to them, and when one 
breaks out it may be followed by others, and the illness 
extend over some weeks ; not only so, but the skin under 
these circumstances is in an irritable condition, and, unless 
great care be exercised, the original boil becomes sur- 
rounded by a number. This is more particularly the case 
where poulticing has been carried on with vigor. 

In adults, boils are often the result of over-feeding, and 
some of the most intractable cases the author has met with 
have been in large eaters of meat ; but in children this is 
not so. A deteriorated state is generally indicated, which 
requires more generous living and sometimes stimulants. 
Occasionally the boils refuse to disappear, except under 
change of air. They may occur on any part of the body, 
but the back of the neck is the most common seat, or the 
buttocks. Sometimes they may be due to defective drain- 
age. 

Treatment. — Every household either has, or can learn 
from its nearest neighbor, a recipe both for a plaster and a 
nostrum for the speedy cure of boils, but there is nothing 
that can be said to show a large percentage of successes. 
Hebra's ungt. diachyli is a good application. Locally, the 
inflammation must be shielded from all irritation (the pain 
they give, however, insures this), and they may be kept 
moist by lead lotion or soft by vaseline or carbolic oil. In 
the early stages the removal of the small head, and the 
insertion of a minute drop of the pharmacopceial glycerinum 
acidi carbolici, sometimes eases the pain and arrests the 
extension of the slough. Poultices and cold-water dressing, 
though in many respects grateful, are dangerously liable to 
provoke a recurrence. As internal remedies, Dusart's or 
Easton's syrup may be given, and maltine or stout. For 



73$ DISEASES OF CHILDREN. " 

growing boys of ten to fourteen or more, a mid-morning 
meal of half a tumbler of stout, with some bread and butter, 
is a very good pick-me-up. 

Sulphide of calcium has been recommended as especially 
valuable, but on two rather contradictory grounds : one will 
recommend it as effective in procuring resolution, another 
as a means of bringing about softening and evacuation. 
The author has sometimes thought it of use in the latter 
way, but it has often failed, and he is not sure of its value. 
In general terms, we must look out for any faults in diet, or 
faults in hygiene, and then, having remedied these, betake 
ourselves to general tonics, such as named, and to maltine 
or stout as a food. 

7. Bromide Eruption. — This is known at sight by those 
who have once seen it, but it is not common. The appear- 
ances are most peculiar. Large fungating bosses of dryish, 
red, warty granulations rise sharply from the skin, which is 
apparently healthy, or which has but the thinnest line of 
inflammation surrounding them. The masses look sore, 
yet do not discharge much, and they are more like con- 
dylomata than any other affection. A very similar erup- 
tion sometimes results in adults from iodide of potassium, 
but the author has never seen it in children. The far com- 
moner papular or acneiform rash may be seen at any age, 
either from iodide or bromide, although it is not common 
in children. The condylomatous form of the disease is a 
severe localized dermatitis, and usually breaks out, if at all, 
after a prolonged use, but it has been known to occur after 
the administration of but a few grains of the drug. 

Treatment. — The drug must be at once discontinued, and 
the part treated as any local ulcer might suggest. It has 
been stated that the combination of arsenic with the salt of 
bromine mitigates the tendency to the outbreak of this 



HERPES. 739 

affection. The eruption is tediously slow in disappearing. 
Dr. Goodhart has known it to last as dried -up crusts for 
four months. 

8. Herpes is most commonly seen round the mouth. 
Its usual appearance is that of a collection of crusts, the 
vesicles characteristic of the disease having become abraded 
and dry. It is often associated with ulceration of the gums, 
and is liable to accompany acute febrile disturbance of any 
sort. It is, however, very commonly seen in the out-patient 
room in conditions of feeble health, without any certain 
evidence of the preexistence of fever. 

Herpes zoster, or shingles, is also common. It occurs 
as a crop of vesicles containing neutral or feebly-alkaline 
fluid, mapping out the distribution of one or other of the 
cutaneous nerves. Of ten cases, two affected the super- 
ficial cervical plexus; four the ilio-inguinal, lumbar, or 
cutaneous nerves of the thigh ; one the internal cutaneous 
of the arm ; three the intercostal nerves ; the right side was 
affected seven times. Six were boys, four girls. The com- 
plaint is, in my experience, as has also been stated by 
others, more common in children than in adults. It is said 
to occur only once in each individual ; a statement we can 
neither confirm nor confute. It is a disease which is asso- 
ciated with more or less pain for a few hours before and 
during the formation of the vesicles ; but this usually quickly 
ceases, the vesicles dry up, though remaining tender, and 
in four or five days the disease is all but well. 

Herpes iris is rare : it is said to occur most frequently in 
the extremities, rarely on the face. In the two cases of 
which the author happened to have notes it occurred in the 
latter situation. It is recognized by a central vesicle, with 
secondary rings of vesicles, and more or less redness around 
them. 

Treatment. — Very little is required for any form of herpes. 



24° DISEASES OF CHILDREN. 

Some mild saline laxative may be given for a day or two, 
and, if the pain be severe, a small dose of opium; the saline 
is to be followed by a tonic. Quinia is very useful. The 
eruption may be treated by the application of some thick 
ointment, such as the unguentum zinci oxidi, which in a 
measure protects the vesicles from friction, and thus eases 
the pain and gives time for them to shrivel ; or they may be 
kept well powdered with the sanitary rose powder, oxide or 
oleate of zinc ; or they may be painted with flexible collo- 
dion. The part should be well covered with wool. 

9. Pemphigus is a not very uncommon disease in child- 
hood. Two forms require mention, pemphigus neonatorum, 
and pemphigus occurring in children other than sucklings. 

To take the last first : it occurs usually in spare children, 
and, if extensive, may be associated with very obvious ill- 
health ; but this is not necessary. Its course is apyrexial in 
many cases. In three cases which have come under notice 
while writing this, one is a spare girl, but not in any strik- 
ingly wasted condition, nor by any means anaemic ; another 
is a remarkably well-looking, stout country boy ; and the 
third — a boy, the disease having lasted for many months — 
as it is likely to do — is somewhat anaemic and thin. 

In all these cases there comes upon the healthy skin a 
patch of erythema. This may be bright red from excessive 
injection of the cutaneous capillaries, or a paler, more cop- 
pery tint. The patch becomes slightly raised, the cuticle 
becoming partially separated, and giving it a wrinkled, soft, 
leathery appearance. After this a full or flaccid bulla forms 
upon a slightly vascular non-indurated base, containing 
opalescent serum or thin puriform fluid. The vesicles rup- 
ture and dry after a certain time of tension, or gradually 
shrivel, with a dry crust forming in the centre. Ultimately 
the whole surface originally blistered becomes covered with 
a thin crust, which covers a superficial ulcer. This gradu- 



PEMPHIGUS. 741 

ally heals, and leaves behind it a brightly rose-colored or a 
coppery stain. 

Under arsenical treatment the blister formation is either 
entirely arrested or rendered abortive. In the latter case 
the trunk and extremities (legs particularly) may be covered 
with coppery patches of slightly thickened skin, not at all 
unlike a condition of tinea versicolor on superficial exami- 
nation. 

It is a disease which is very prone to relapse and to recur 
through several years, but, according to Hutchinson, it is 
cured eventually under arsenical treatment. The author 
had two cases which strikingly illustrate the tendency to 
relapse, the intractability as regards complete cure, but the 
ready temporary cure under the administration of arsenic 
—a boy of five and a half, who has been in the hospital 
twice, with an interval of some months, and who has been 
under medical treatment more or less for many months. 
Small doses of arsenic are of little use to him, but as soon 
as fifteen-minim doses are reached, the blebs shrivel and no 
fresh ones appear. But here comes his difficulty : a less 
dose fails to check the formation of vesicles ; the large dose, 
when continued for ten days or a fortnight, causes diarrhoea 
and vomiting, and necessitates its discontinuance. 

Pemphigus neonatorum is sometimes a disease of like 
character to that just described. It then appears as scat- 
tered bullae in various parts of the body, avoiding the soles 
of the feet and the palms, and but rarely affecting the scalp. 

Bullae have occasionally been seen upon the gums and 
mucous membrane of the mouth. More commonly, how- 
ever, it is more acute and more diffused, sometimes being 
more of the nature of a general dermatitis, and is frequently 
of syphilitic origin. Syphilitic pemphigus is particularly 
prone to affect the soles and palms. 

The descriptions of pemphigus vary much. One can 



742 DISEASES OF CHILDREN. 

therefore only suppose that the disease varies in its symp- 
toms. Thus, a cachectic form is described by some, because 
it occurs in unhealthy children ; a pyaemic by others, because 
it occasionally indicates some bad condition of blood ; some 
have witnessed a contagious form ; and it is described as 
being sometimes associated with fever, sometimes not. 

Diagnosis. — This is for the most part not difficult, for the 
existence of scattered blisters determines it. But when, as 
may happen, the bladders have dried and crusted, or the 
disease is acute and diffused, and the body is covered with 
eczematous-looking crusts, one may well hesitate before 
coming to a conclusion. 

Prognosis. — This is only grave in young infants, or in the 
diffused forms in cachectic, pyaemic, or syphilitic infants. 

Treatmejit. — English authorities now very generally assent 
to the doctrine that arsenic is curative of non-syphilitic pem- 
phigus. Abroad, opinion is by no means unanimous, and, 
by many, general tonics and blood restorers, such as cod- 
liver oil, iron, etc., are preferred before other remedies. 

The evidence collected by Hutchinson in favor of arsenic 
is very strong. It has been corroborated by a large number 
of other observers, and it so rarely fails to relieve and, event- 
ually, to cure the disease, that it may fairly be called the 
treatment for pemphigus. Other means for improving the 
general health may well be resorted to at the same time, 
and, while such things as cod-liver oil and iron are given 
internally, good food and fresh air should be provided also. 

For syphilitic cases anti-syphilitic remedies, such as hyd. 
c. cret, or iodide of iron, are to be given internally, or a 
mercurial bath may be given externally, of a strength of two, 
three, or four grains to each gallon of water. 

The blebs may be powdered over with boracic acid or 
oleate of zinc, to encourage their shriveling, drying, and 
healing. 



ERYTHEMA. 743 

io. Psoriasis is often hereditary. It presents similar fea- 
tures in childhood to those of the disease in adults, and it is 
for the most part relieved by similar remedies — viz., the 
local application of tar soap and tar ointments, and the in- 
ternal administration of arsenic ; but it is an intractable 
form of disease in children. The sapo carbonis detergens, 
or terebene soap, is good for these cases, and the oil of cade, 
one part to three of vaseline, with some oil of lavender, 
makes a serviceable ointment ; as also does liq. carbonis 
detergens 5j to vaseline Sj to §ij. The ung. acidi chryso- 
phanici (ten grains to the ounce of benzoated lard) is also 
a useful remedy, but must be used with care, as it some- 
times produces oedema, and some slight local inflammation 
of the part to which it is applied. It also stains the skin 
and linen, but the color can be removed by benzol or weak 
solutions of potash (Martindale). 

ii. Erythema may assume various forms. A wander- 
ing one, of erysipelatous nature, is not uncommon in young 
infants in out-patient practice among the poor. The skin 
and subcutaneous tissue are the prey of a metastatic oedema 
which flits from spot to spot. It is, in Dr. Goodhart's ex- 
perience, almost always fatal, even when — and this is not 
rare — the constitutional disturbance is hardly apparent. 
The disease is probably of septic nature, and attention 
should be given to the condition of the umbilical sore, and 
the general hygiene of the house should be made the sub- 
ject of special inquiry. Erythema nodosum is, however, 
alone definite enough to warrant more special notice. It is 
not uncommon. It is characterized by raised and tender 
lumps, which appear most often about the legs, on the front 
of the shin, and about the calf. They are not so very uncom- 
mon over the exterior of the foiearm. The lumps quickly 
change color and pass through the phases of discoloration 
of a bruise, and gradually disappear. Erythema nodosum 



744 DISEASES OF CHILDREN. 

is often associated with other forms of erythema, and has 
thus received the name of erythema multiforme. The dis- 
ease occurs in rheumatic families, though not exclusively so. 
It is usually attended by apparent ill -health, but the tem- 
perature is hardly raised. 

It is but seldom necessary to apply any local treatment, 
but, after paying attention to the bowels, a tonic of iron, or 
arsenic, or strychnia should be given. 

12. Sclerema Neonatorum hardly comes within the 
range of practical medicine, it is so rarely seen. It appears 
to be a disease of the newborn among the poor of large 
towns, and to be more common in the winter than the sum- 
mer months. The affection is stated to begin in the lower 
extremities as a hard or brawny oedema, which gradually 
spreads over the body. The suppleness of the skin 
becomes lost, and it is impossible to raise it with the fingers 
from the deeper parts ; skin, muscle, and bone appear as one 
solid log. The body heat sinks at the same time, the pulse 
becomes imperceptible, the heart sounds almost inaudible, 
and may be the respiratory movements are invisible. The 
infant thus becomes excessively feeble, sucks little, takes 
little from the breast, and sinks. 

Parrot distinguishes between sclerema — in which the skin 
is hard and thickened by new material, while the fat is 
shriveled and atrophied — and oedema of the newborn ; 
but these two conditions have usually been confused. In 
this distinction he is followed by Henoch, and no doubt 
correctly. Of the cause of sclerema we are still quite in 
ignorance, but of oedema some cases originate in erysipelas, 
others in extreme atelectasis or weakness of the heart, and 
others, perhaps, in nephritis in early infancy, of which 
Henoch gives a case in an infant of four weeks old. 

In either case, however, the actual result seems much the 
same, and the post-mortem examination reveals visceral 



SEBORRHCEA. 745 

changes of like character in both — viz., atelectasis, lobular 
pneumonia, and various other lesions of dubious meaning, 
such as capillary infarctions, etc. 

Gerhardt attributes sclerema in great measure to lowering 
of the body temperature in feeble premature children, and 
in this light he advocates careful feeding, either by wet- 
nurse or otherwise ; and all such means as will raise the 
temperature — warm baths, hot packs, etc. Dr. Goodhart 
has seen several examples of diffused scleroderma in chil- 
dren of six to ten years of age, and one case, a boy of seven 
years, under the care of Mr. F. D. Atkins, of Sutton, is of 
especial interest, because it followed directly upon albu- 
minuric dropsy after a sore throat and eruption of doubtful 
nature, but unlike that of scarlatina. The disease, however, 
does not differ apparently from that of adult age. 

13. Seborrhcea is an affection of the sebaceous glands, 
and, as affecting the scalp, it is not uncommon in infants, 
leading to a thick caking of the scalp, usually about the 
front, and to a secondary dermatitis ; while in older children 
it occasionally produces a condition of intolerable scurf. In 
the former class of cases, the crusted material must be 
softened by carbolic oil and poultices, and then removed — 
the further reaccumulation of material must be prevented 
by plenty of soap and warm water, and, if necessary, friction 
of the scalp with unguentum myristicae or some other mild 
stimulant. In older children, the hair should be kept short, 
frequently well washed with soap, and the scalp stimulated 
by being well brushed at least twice a day. Oily applica- 
tions, such as weak carbolic oil or vaseline scented with oil 
of lavender, are useful, inasmuch as they prevent the accumu- 
lation of the natural secretion, and thus make a far more 
healthy condition of the affected glands. Boracic acid in 
glycerine is also useful in the same way, and acts, moreover, 
as a mild stimulant. 



74-6 DISEASES OF CHILDREN. 

There are various other affections of the skin which might 
be mentioned, but they are rare — almost unimportant — and 
may well be left to special works on the subject. Keloid 
need only be mentioned as not uncommon in vaccination 
scars, and therefore affording opportunity for the study of 
the natural history of a very remarkable form of tumor, in 
that it tends to disappear spontaneously. 

14. Molluscum Contagiosum also, as a form of glandular 
tumor, occurring about the face, neck, chest, genitals, etc., 
which many assert to be contagious, is a disease which, 
insignificant in itself, is of great pathological interest. It is 
easily eradicated by nipping off the little masses with the 
nail, and, if necessary, applying some mild astringent, or 
touching the bases with caustic. 

15. Congenital Xanthelasma may also find mention, in 
that it also may help, though of very exceptional occurrence, 
to a clearer knowledge of a still obscure disease in the 
adult. 

There yet remain the important group of parasitic dis- 
eases. These are tinea, with which alopecia areata may be 
coupled for the sake of convenience, favus, scabies and pedi- 
culi. 

16. Tinea is rare in infants, but it is occasionally seen 
even in sucklings. It is very common in older children. 
It occurs in two forms — the body tinea, when it appears as 
a red, scurfy, gradually spreading ring on face, neck, arms, 
or other parts ; and the scalp tinea, which requires a more 
detailed description. Both forms are due to the same 
fungus, the tricophyton tonsurans. This is seen in minute 
spores, which form strings or thickly clustered masses, 
which have been compared to fish-roe, and which are inde- 
structible by liq. potassae or by aether (the latter distin- 
guishes them from small globules of fatty matter, which 
sometimes make a difficulty in diagnosis for the student). 



TINEA. 747 

It occurs in the scalp as isolated patches, which are more 
or less bald ; or diffused, without any definite baldness any- 
where. The scalp often presents the appearance of eczema 
or seborrhcea, and sometimes, though rarely, there is pustu- 
lation. The characteristic of the disease is the existence at 
any part of short, bristly stumps, or hair-follicles with a 
central black dot (which is the hair broken off quite short, 
or the empty orifice occluded by dust), or persistently bar- 
ren, though slightly swollen, hair-follicles. The isolated 
patches are often red or scurfy ; but the diffused disease is 
very difficult to detect, unless the scalp be very carefully 
examined, and the short stumps of broken-off hair be made 
the special object of search. 

Diagnosis. — As regards this, the disease is so common 
and so often overlooked, that a diseased scalp of any kind 
should always be examined with the possibility of its 
existence in view. Scurfy heads particularly require this, 
as the stumps are liable to be hidden beneath the scales. 
The scalp must be examined methodically, the hairs being 
turned up with a pair of forceps, and the roots examined 
with a lens. Any suspicious stump must be (as much of 
it as possible) extracted, and the minute fragment examined 
under the microscope, after adding a drop of liquor potassse 
to clear the parts. 

Prognosis. — Recent cases are for the most part readily 
curable under energetic treatment ; when the disease has 
existed some months, it may be very intractable. Even 
recent cases, however, require a guarded opinion upon the 
speediness of recovery, for some children appear to form an 
unusually favorable soil for its growth, and the disease 
spreads with great rapidity, notwithstanding treatment. It 
is impossible to say what the conditions in the child may 
be which favor the growth of tinea. The late Sir Erasmus 
Wilson believed that they were those of a depressed vitality 



74$ DISEASES OF CHILDREN. 

which required extra food, and tinea is no doubt often 
found in thin anaemic children ; but there is equally no 
doubt that it is not uncommon in those who appear to be 
in very good health. 

Treatment. — It is only necessary to give a bare outline 
here. For fuller information the reader cannot do better 
than refer to Mr. Alder Smith's little book,* than which 
nothing could be more simple, precise, and admirable, and 
from which, fully convinced of its value by personal expe- 
rience, much of the advice which follows is condensed. 
Tinea upon the body is readily cured. Hyposulphite of 
sodium (5j ad 5j), boracic acid dissolved in glycerine, iodine 
liniment, perchloride of iron, citrine ointment, and oleate 
of mercury, are all effective. Tinea upon the scalp is a 
much more troublesome affair, because the fungus dips 
down into the hair-follicles, and invades the hair itself. 
It is therefore difficult to get at the fungus, and of course 
this difficulty is proportionate to the duration of the 
disease. 

In all cases the hair upon, and for half an inch around, 
the patch is to be cut short. If the disease is at all exten- 
sive, the hair is to be cut to a two-inch length all over the 
head, a fringe being left back and front for the sake of the 
appearance. 

In recent cases the head is to be washed every morning, 
or every other morning, with carbolic soap, then well 
mopped with a lotion of hyposulphite of sodium (5j to the 
§j). The actual patches may be blistered with glacial acetic 
acid, and afterwards some parasiticide applied — glycerine of 
carbolic acid, one in five is a good one ; but Alder Smith 
recommends, above all things, an ointment of nitrate of 
mercury, sulphur, and carbolic acid — 

*" Ringworm; its Diagnosis and Treatment," 2d edition. 



TINEA. 749 

]£ . Acid carbol., Calvert's No. 2, 

Ungt. hydrarg. nitrat., 

Ungt. sulphuris, 
The proportions will vary with the age of the child. Equal parts will 
be borne by children of ten. 

This must be well pressed into the roots of the hair-follicles 
three times a day. Carbolic oil, one to ten, or — 

R. Hydrarg. amnion., gr. vj. 

Hydrarg. ox. rubra., gr. vj. 

Olei amygdalae dulc, mjj. 

Adipis benzoat., ^j. 

are good applications for the entire scalp. Epilation should 
be practiced over the diseased parts. 

When the disease is extensive, a weak ointment must be 
applied all over the head. If the head should become sore, 
the parasiticide is to be applied by painting only. 

In chronic ringworm the fungus will have reached the 
depth of the hair-follicles, and be more or less inaccessible 
to the effects of the parasiticide. Under these circumstances 
stronger remedies become necessary, and oleate of mercury 
appears to be one of the best applications. In children over 
ten, a ten per cent, solution may be used ; under five, a five 
per cent, solution. The oleate is to be well pressed into the 
diseased patches with a firm mop night and morning, the 
rest of the head being smeared with either carbolic oil or the 
weak compound ointment already mentioned. If the 
disease be extensive, the oleate must be rubbed into the 
entire head. The head must not be washed oftener than once 
in ten days under the use of the oleate ; frequent washing 
impedes the penetration of the remedy. The hair must be 
kept short. This treatment will require to be continued for 
some time, often for several months. Mr. Alder Smith states 
that it is extremely rare for any ill effects to follow the use 
of the mercurial. 

63 



750 DISEASES OF CHILDREN. 

In cases which resist even this treatment, the artificial 
production of kerion is recommended. This is, in short, the 
production of an cedematous inflammation of the scalp in 
such patches as are diseased. It must be done very cau- 
tiously, and only a small patch at a time, and the parents 
should be informed of the aim of the treatment. 

Croton oil is an efficient remedy for this purpose. This 
is painted on night and morning, and the part poulticed 
assiduously. In four or five days' time the scalp thus treated 
should be red, swollen, boggy, tender, and the stumps pro- 
truding from the swollen follicles. Epilation is then to be 
carried out, and carbolic oil, citrine and sulphur ointment, 
thymol, or some other parasiticide is to be applied to the 
surface. 

Water-dressing or weak carbolic oil may be applied to 
the parts until the inflammation subsides, when usually the 
disease is cured, and a smooth, shining, bald patch results. 
Some stimulant hair-wash is then to be rubbed into the bald 
patches night and morning, and the hair is soon reproduced. 
This treatment is severe, should never be applied to young 
children under seven or eight, and only in cases in which 
energetic treatment of milder fashion over a long time has 
failed to eradicate the disease. 

Other forms of treatment for ringworm might be men- 
tioned by the score. The following are the details of two 
methods which have of late been recommended, and which 
have their merits. The first is that by iodine and turpen- 
tine, advocated by Dr. Foulis. The hair is cut short, and 
the head well washed with carbolic soap of ten per cent, 
strength. The diseased patches are then rubbed with tur- 
pentine, by the finger, for three or four minutes, until the 
part begins to sting, when tincture of iodine is painted on 
in two or three coats. The turpentine removes the grease 
from the scalp and follicles, and allows the iodine, which is a 



TINEA. 751 

powerful parasiticide, to penetrate and reach the fungus. 
It should be applied every night, or every night and morn- 
ing in severe cases, and is said to give no pain even to the 
youngest child. Dr. Goodhart, however, found it to cause 
considerable pain at times. The other treatment is that of 
Dr. Harrison, of Bristol. The hair is cut short and the 
diseased patches are painted with a solution of equal parts of 
liquor potassae and rectified spirit, to which half a drachm 
per ounce of iodide of potassium has been added. The 
solution being strongly caustic, should be applied cautiously, 
and only to a small patch, until the resisting power of the 
scalp is ascertained. This solution is dabbed on to the 
part for two or three minutes at a time, at intervals of two 
or three days, twice or three times, according to the size of 
the patch and the severity of the complaint, and then a 
solution of four grains of mercuric chloride in an ounce of 
equal parts of rectified spirit and water is taken. This is 
first painted on the disease ten minutes after the last appli- 
cation of the iodide and potash, and it is reapplied two or 
three times at two days' interval. Dr. Harrison recom- 
mends a few days' rest after this, and then recommence the 
treatment ; and it should not be applied to heads that have 
recently been under active treatment in any form without 
a period of freedom. 

Ringworm is very liable to relapse, and no child should 
be considered cured until the new downy hair is growing 
well and no stumps are to be seen, and this after several 
examinations made at intervals. 

The disease is contagious, and liable to spread in families 
or schools ; therefore all brushes, combs, sponges, flannels, 
towels, etc., used by the infected, must be scrupulously kept 
separate, and no other child allowed to touch them. Caps, 
coats, comforters, etc., must be kept quite separate, and 
well baked when no longer needed, or, still better, destroyed 



752 DISEASES OF CHILDREN. 

all linen that will wash should be well boiled. The heads 
of all other children in the house should be well pomaded 
with white precipitate ointment, scented so as to render 
it agreeable, or with carbolic oil (i to 10). They should 
also be frequently washed and examined once a week, so 
that no early spots may go undetected. Recent cases of 
the disease, or any case where the disease is extensive, 
should be isolated. In the very chronic cases, when the dis- 
ease is well in hand, and the head effectively covered with a 
parasiticide, etc., the child may, if it be imperative, mix with 
other children, without much fear of the disease being 
communicated. It is, of course, better, when possible, to 
isolate the child until it is well. No boy should be sent back 
to school unless he be absolutely well, or the disease be well 
lander treatment and the medical officer consents to his 
return, it being, of course, fully understood that continued 
supervision and treatment will be necessary. 

Ringworm is very liable to relapse, and no child should 
be considered cured until the new downy hair is growing 
well and no stumps are to be seen, and this after several 
examinations made at intervals. 

17. Alopecia Areata is placed here because so much dis- 
cussion has taken place as to whether it is or is not due to 
the growth of a fungus, and because, if it be not, it is a con- 
dition which might be mistaken for ringworm. The fact 
that authorities have hitherto been divided upon the para- 
sitic nature of this affection seems to me to point unmistak- 
ably to the conclusion that there is a disease (alopecia 
areata) which is non-parasitic, and that ringworm sometimes 
puts on very much the same appearances. The majority of 
living dermatologists are of opinion that alopecia areata is 
not due to a fungus. Alopecia is of various kinds, and any 
one of them may be found in childhood ; but the disease, 
which occurs in patches, is apparently distinct from these, 



favus. 753 

although the condition of the hair is, equally with them, one 
of simple atrophy. The cause of this atrophy is unknown ; 
it is said to be sometimes hereditary. The hair falls out in 
patches, which increase at the circumference, and sometimes 
the entire scalp becomes bald. It is a common disease of 
children, and is treated — and as a rule successfully — by 
stimulant applications to the scalp. The expressed oil of 
nutmeg, well rubbed into the patch night and morning, is a 
good remedy. Another favorite prescription is tincture of 
cantharides, carbonate of ammonium, spirits of rosemary, 
and water: — 

&. Ammon. carbonat., 3 ss. 

Tinct. cantharides, f ^ iss. 

Spt. rosmarini, f £ ss. 

Aqua?, q. s., adf^vj. 

Tincture of iodine may be applied, or, if the case prove 
obstinate, a patch may be gently vesicated, if not too large, 
by blistering fluid or iodine liniment. Steiner quotes 
Rindfleisch as recommending a lotion of tincture of cap- 
sicum and glycerine, and it is one that should prove use- 
ful. The child will probably be benefited by tonics and 
good living. 

18. Favus. — Of this disease no lengthy mention is re- 
quired, it is so rare. The author has seen it only twice, 
and it is very uncommon in America. Kaposi notes its 
occurrence fifty-six times in a total of nearly 26,000 cases 
of skin disease in a period of ten years. It appears as 
crusted cups of sulphur-yellow color scattered over the 
scalp, and can scarcely be mistaken, though in very long- 
standing cases it may perhaps be so for the crusts of some 
other disease — psoriasis, neglected eczema, seborrhcea, etc. 
The patches are more or less circular, of well-marked out- 
line, situated round one or more hair-follicles, and when 



754 DISEASES OF CHILDREN. 

removed leave a moist, depressed surface of skin behind. 
Favus sometimes occurs upon the body, and sometimes 
affects the nails. 

Treatment. — This is expressed, in short, by epilation, and 
the energetic application of some parasiticide afterward. 
The ointment already given for tinea tonsurans may be 
recommended. Kaposi states that it is unnecessary to 
epilate the hairs systematically all over the diseased area, 
all that is necessary being to take the hair in thin tufts 
— healthy and diseased indiscriminately — between such a 
thing as a spatula and the thumb, and then to make slight 
traction. By this means the diseased and loose hairs come 
away and leave the healthy behind, without causing pain. 
Any cakes of fungus must first of all be removed by the 
free inunction of oil, and by poulticing, and the parasiticide 
is to be rubbed in after every epilation. The disease is 
intractable, and requires long treatment. 

19. Scabies is a common ailment in the out-patient 
rooms of children's hospitals. It is often generalized over 
the body, it is often pustular, and it may be associated with 
an eruption of an eczematous appearance. It may in some 
cases be mistaken for eczema or impetigo, both common 
diseases in children ; and it is also not easy to distinguish 
at first sight from lichen urticatus or strophulus, if the latter 
be very diffused and the skin scored by scratching. 

Diagnosis. — This must be settled by detecting the acari. 
Should the burrows prove difficult to find, any eczematous 
crusts may be scraped and detached and examined under 
the microscope for fragments of the acari, or ova. 

Treatment. — This consists of applying some parasiticide 
to the affected parts, and afterwards thorough bathing — the 
infected clothes being well boiled or baked. Sulphur is the 
commonest remedy; half a drachm to an ounce of vaseline 
makes a good application. The late Tilbury Fox recom- 



pediculi. 755 

mended an ointment of sulphur, ammoniated mercury, and 
creasote : — 

R . Sulphuris, ^ ss. 

Hydrarg. atnmon., gr. iv. 

Creasoti, W^iv. 

01. anthemidis, tr\x. 

Adipis, ify). 

Iodide of potassium ointment is said to be very effica- 
cious, and has the advantage of having no smell. To 
pustules and inflamed parts a soothing lotion, such as lotio 
plumbi, must be applied. When the disease is generalized, 
time is saved by rubbing the sulphur ointment into the 
whole surface, the child remaining in a well-sulphured shirt 
and sheets for forty-eight hours. A thorough bath is then 
given, and clean clothing put on. But this plan can only 
be followed when the skin is sufficiently sound to allow of 
it; it is not advisable in eczematous or pustular conditions. 
It will then be necessary to single out such parts as admit 
of and require the parasiticide, and others for the emollient 
treatment. 

20. Pediculi are mostly seen in the head. As a broad 
rule, enlargements of the glands in the segment of the neck 
behind the ears are caused by impetigo of the scalp, and 
impetigo is always associated with pediculi. Pediculi are 
often present without the pustulation ; but given the existence 
of the latter, the former will generally be found. They are 
for the most part recognized by the existence of the ova on 
the hair ; these are readily recognized by their elongated 
shape and their adhesion to the hair. 

Treatment. — The hair should be thinned as much as 
possible ; in boys it may be cropped close to the head. 
If the head is not sore, the hair may be bathed with vinegar 
and water, with the object of loosening the cement which 
unites the ova to the hair, and thus to allow of their re- 



756 DISEASES OF CHILDREN. 

moval by subsequent washing with soap and water. The 
ung. hyd. ammon., either undiluted or mixed with vaseline, 
and scented with oil of lavender, is perhaps, upon the whole, 
the best parasiticide. Some prefer a lotion of bichloride of 
mercury (two to four grains to the ounce), and benzol is 
recommended by others ; but the ointment is, perhaps, 
safer than the one, and less repulsive than the other. 
Pediculi are not usually troublesome to eradicate, when 
once attention is directed to their existence. It perhaps 
more often happens that parents apply one thing after 
another to cure a sore head, and take no radical measures 
against the pediculi which are at the root of the mischief. 
When they are few in number, a fine comb and frequent 
washing with soap and water will easily remove them. 

One other point needs noting — viz., that pediculi are 
not always due to uncleanliness. It is no unfamiliar experi- 
ence, that the heads of patients in every way well tended 
may, as it were, suddenly swarm with vermin when disease 
has reached the stage of exhaustion preceding dissolution ; 
and with children it is true, as said of tinea, that ill health 
of any form, but particularly the thin, miserable starveling, 
is the prey of these creatures of vulturous propensities. 
Fattening food and tonics are therefore very usually requi- 
site in these cases. 



NDEX. 



Abdomen, 21 

method of examining, 23 
Abdominal neuroses, 141 

symptoms of, 141 
Abscess, peritoneal, 188 

diagnosis of, 188 
treatment of, 189 
retro-pharyngeal, 78 
Acute bronchitis, 612 

symptoms of, 613 
diagnosis of, 615 
prognosis of, 616 
treatment of, 616 
endocarditis, 688 

in rheumatism, 376 
membranous laryngitis, 602 
nephritis, 716 
pericarditis, 687 

in rheumatism, 376 
pleurisy in rheumatism, 376 
rheumatism, 374 
tonsillitis, 71 
tuberculosis, 393 

pathology of, 393 
symptoms of, 395 
diagnosis of, 396 
prognosis of, 397 
treatment of, 397 
urticaria, 732 

treatment of, 732 
vomiting, 87 
Ague, 343 

Ailments of dentition, 52 
treatment of, 53 
second dentition, 55 
Albuminuria in diphtheria, 259 

in scarlet fever, 219 
Alcohol, 28 
Alopecia areata, 752 

treatment of, 753 

64 



Ammonia, aromatic spirits of, 28 

Anaemia, 442 

diagnosis of, 443 
prognosis of, 443 
treatment of, 413 

Analysis of humanized milk, 42 

Anasarca, 219 

Anatomical lesions of cholera infan- 
tum, 125 
febrile diarrhoea, 117 

Anatomy, morbid, of atelectasis, 644 
of bronchiectasis, 621 
of chorea, 564 
of chronic bronchitis, 618 
of cretinism, 552 
of diphtheria, 261 
of disease of the spleen, 432 
of encephalic tumors, 480 
of gangrenous stomatitis, 63 
of hemiplegia, 511 
of hydrocephalus, 468 
of infantile paralysis, 493 
of intussusception, 1 51 
of late rickets, 370 
of lienteric diarrhoea, 133 
of measles, 202 
of mumps, 298 
of pertussis, 316 
of phthisis, 651 
of pleurisy, 668 
of pneumonia, 625 
of pseudo-hypertrophic pa- 
ralysis, 514 
of rickets, 358 
of scarlet fever, 230 
of tabes mesenterica, 412 
of typhoid fever, 334 
of whooping-cough, 316 

Aneurism, 707 

Antiseptic precautions in intussuscep- 
tion, 169 



7S7 



758 



INDEX. 



Anuria, 7 1 1 

treatment of, 712 
Appendix, perforation of, 184 
Aphthous stomatitis, 56 
Arsenic, 28 
Artificial digestion, 40 
Ascaris lumbricoides, 162 
Ascites, 189 

causes of, 190 

diagnosis of, 190 

treatment of, 191 

paracentesis in, 191 
Atelectasis, 641 

causes of, 641 

symptoms of, 643 

morbid anatomy of, 644 

diagnosis of, 646 

prognosis of, 646 

treatment of, 647 

following pertussis, 311 
Atrophy, 96 
Atropise, liquor, 324 
Auscultation, 220, 582 



Barley water, 33 

Bastard measles, 244 

Baths, 29 

Beef-tea, 45 

Belladonna, 28 

Blood-poisoning in diphtheria, 256 

Boils, 736 

treatment of, 737 
Bottle, graduated nursing, 49 
Bottles, hot, 30 
Brain, hypertrophy of, 483 
Bromide of potassium, 27 
eruption, 738 

treatment of, 738 
Bronchial phthisis, 404 

symptoms of, 406 
diagnosis of, 407 
prognosis of, 408 
treatment of, 408 
trouble in measles, 197 
Bronchiectasis, 620 
causes of, 620 
morbid anatomy of, 621 
prognosis of, 622 
treatment of, 622 
Bronchitis, acute, 612 
causes of, 612 
symptoms of, 613 



Bronchitis, diagnosis of, 615 

prognosis of, 616 

treatment of, 616 
chronic, 617 

morbid anatomy of, 618 

prognosis of, 618 

treatment of, 619 
Broncho-pneumonia in measles, 310 
Bruit Skodique, 665 



Caecum, perforation of, 184 
Cafe-au-lait tint in syphilis, 418 
Calculus vesica, 726 

diagnosis of, 726 
Castor-oil, 29 
Catarrhal enteritis, 1 16 
pneumonia, 634 

temperature chart of, 635 
stage of whooping-cough, 303 
stomatitis, 56 
Causes of acute bronchitis, 612 

ascites, 190 

atelectasis, 641 

bronchiectasis, 620 

coryza, 584 

diphtheria, 264 

dysuria, 712 

heart disease, 684 

hemiplegia, 507 

pleurisy, 660 

pneumonia, 629 

pseudo-croup, 589 

rickets, 346 

typhlo-peritonitis, 181 
Cerebral hemorrhage, 485 

symptoms of, 486 

diagnosis of, 487 

prognosis of, 487 

treatment of, 487 
Cervical opisthotonos, 527 
Cestodes, 162 

Chapman's entire wheaten flour, 45 
Cheadle's formula, no * 
Chest, 20 

examination of, 21, 580 
shape of, in tubercular subjects, 650 
Cheyne-Stokes respiration, 580 
Child, examination of, 15 
complexion of the, 20 
points to be observed in exam- 
ining, 17 



INDEX. 



759 



Child, the cry of, 1 8 
Cholera infantum, 125 

anatomical lesions of, 125 

etiology of, 125 

symptoms of, 125 

diagnosis of, 126 

prognosis of, 127 

treatment of, 128 
Chorea, 556 

morbid anatomy of, 564 

age of most frequent occurrence, 

567 
complications of, 573 
prognosis of, 573 
treatment of, 574 
diet in, 576 
magna, 555 
Chronic Bright's disease, 717 
bronchitis, 617 

morbid anatomy of, 61S 
prognosis of, 618 
treatment of, 619 
diarrhoea, 129 

etiology of, 129 
symptoms of, 130 
treatment of, 137 
intussusception, 162 
laryngitis, 604 

diagnosis of, 605 
prognosis of, 606 
treatment of, 606 
pneumonia, 639 
tonsillitis, 74 
vomiting, 88 
Cirrhosis of the liver, 174 

morbid anatomy of, 175 
symptoms of, 175 
Cleft-palate, 69 
Colic, 100 

Complications of chorea, 573 
of diphtheria, 259 
of measles, 198 
of mumps, 297 
of phthisis, 655 
of pleurisy, 668 
of pneumonia, 636 
of rickets, 358 
o.f scarlet fever, 215 
of whooping-cough, 309 
Condensed milk, 35 

fresh, 36 
Congenital xanthelasma, 746 
Constipation, 104 



Constipation, causes of, 104 

treatment of, 104 
Contagion of diphtheria, 266 

of measles, 201 

of rotheln, 246 

of scarlet fever, 210 

of whooping-cough, 301 
Convulsions in dentition, 535 

in whooping-cough, 309 
Coryza, 584 

causes of, 584 

formula for, 54 
Cowling's rule for dosage, 27 
Cows' milk, ^^ 
Cranial bones in syphilis, 420 
Craniotabes as a sign of rickets, 351 
Cretinism, 550 

causes of, 551 

morbid anatomy of, 552 

diagnosis of, 553 

prognosis of, 553 

treatment of, 553 
Croup, false, 588 
Croupous pneumonia, temperature 

chart of, 632 
Crying from hunger, 32 
Cyanosis, 706 
Cynanche parotidea (mumps), So 



Deglutition, 26 

Dental decay, 54 

Dentition and its derangements, 51 
convulsions during, 53 
in rickets, 357 
second, 54 

ailments of, 55 

Desquamation in scarlet fever, 213- 
229 

Diagnosis of acute bronchitis, 615 
laryngitis, 600 
tuberculosis, 396 
of anaemia, 443 
of ascites, 190 
of atelectasis, 646 
of bronchial phthisis, 407 
of calculus vesica?, 726 
of catarrhal pneumonia, 634 
of cerebral hemorrhage, 487 
of cholera infantum, 126 
of chronic laryngitis, 605 
of colic, 100 
of cretinism, 553 



760 



INDEX. 



Diagnosis of diarrhoea, 120 

of diphtheria, 266 
from croup, 267 
from scarlet fever, 208 

ofdysuria, 712 

of encephalic tumors, 480 

of enlargement of the spleen, 433 

of epilepsy, 541 

of flatulence, 100 

of haemophilia, 438 

of hydrocephalus, 437 

of hypertrophy of the pharyngeal 
mucous membrane, 78 

of infantile convulsions, 537 
palsy, 501 

of intussusception, 154 

of lichen urticatus, 728 

of lienteric diarrhoea, 134 

of malarial fever, 344 

of measles, 204 

of mucous disease, 146 

of mumps, 229 

of parotitis, 299 

of pemphigus, 742 

of peritoneal abscess, 188 

of peritonitis, 181 

of pertussis, 317 

of phthisis, 655 

of pleurisy, 669 

of pneumonia, 636 

of progressive muscular atrophy, 

524 
of pseudo croup, 589 
of pseudo-hypertrophic paralysis, 

5 IQ 

of rheumatism, 384 
of rickets, 363 
of roseola, 249 
of rotheln, 248 
of scabies, 754 
of scarlet fever, 234 
of scurvy, 442 
of simple atrophy, 97 
meningitis, 450 

from tubercular, 451 
of spastic paralysis, 529 
of syphilis, 426 
of syphilitic hepatitis, 177 
of tabes mesenterica, 412 
of tinea, 747 

of tubercular meningitis, 463 
of typhlo-peritonitis, 185 
of typhoid fever, 335 



Diagnosis of typhoid fever from men- 
ingitis, 336 
tuberculosis, 336 
of varicella, 287 
of worms, 165 
Diarrhoea, 112 

classification of, 115 
simple, 116 
febrile, 117 
chronic, 129 

etiology of, 129 

symptoms, 130 

treatment, 140 

lienteric, 133 
Diet in chorea, 576 
in diphtheria, 274 
in measles, 205 
in mucous disease, 146 
in rickets, 345 
in scarlet fever, 237 
in typhoid fever, 239 
Digestion, artificial, 40 
Diphtheria, 251 
causes of, 251 
incubation of, 252 
symptoms of, 252 
pyrexia in, 253 
onset of, 253 
the throat in, 253 
the membrane in, 253 
tenderness of glands beneath the 

angle of jaw in, 253 
character of urine in, 254 
laryngeal symptoms in, 253 
causes of death from, 256 
blood-poisoning in, 256 
suffocation in, 258 
complications of, 259 
sequelae of, 259 
albuminuria in, 259 
hyaline casts of, 259 
paralysis in, 260 
morbid anatomy of, 261 
pathology of, 263 
lungs, condition of, in, 202 
contagion of, 266 
micrococcus of, 265 
diagnosis of, 266 

of, from croup, 267 
tonsillitis, 269 
treatment of, 269 

local, 270 
diet in, 274 



INDEX. 



76l 



Diphtheria, tracheotomy for, 275 

rules for tracheotomy in, 278 

intubation for, 280 
Direct spasm of the glottis, 591 
Diseases, acute infectious, 193 

diathetic, 393 

of the genito-urinary organs, 709 

of the heart, 681 

of the intestines, 93 

of the liver, 172 

tubercular, 174 

of the mouth and throat, 5 1 

of the nervous system, 445 

of the organs of respiration, 579 

of the peritoneum, 179 

of the skin, 727 

of the spleen and blood, 431 

of the stomach, 81 

not infectious, 343 
Disinfection after scarlet fever, 229 
Dosage for a child, 26 
Dropsy, scarlatinal, 219 
Dura arachnoid, inflammation of, 445 
Dysentery, 140 

treatment of, 141 
Dysuria, 712 

causes of, 712 

diagnosis of, 712 

treatment of, 712 



Ecthyma, 736 
Eczema, 732 

treatment of, 733 
Egg, yolk of, 45 
Ejecta, the, 26 
Encephalic tumors, 478 

symptoms of, 479 
morbid anatomy of, 480 
diagnosis of, 480 
prognosis of, 482 
treatment of, 482 
Enuresis, 721 

treatment of, 723 
Epiglottis in diphtheria, 261 
Epilepsy, 539 

symptoms of, 540 
diagnosis of, 541 
prognosis of, 541 
treatment of, 541 
Epistaxis, 588 

treatment of, 588 



Epistaxis in whooping-cough, 309 
Eruptive stage of measles, 195 
of rotheln, 247 
of scarlet fever, 211 
of varicella, 284 
Erythema, 743 

treatment of, 744 
Este's solution, 272 
Etiology of cholera infantum, 125 
of chronic diarrhoea, 129 
of febrile diarrhoea, 1 18 
of gangrenous stomatitis, 64 
of measles, 201 
of mumps, 295 
of rickets, 345 
of scarlet fever, 228 
of whooping-cough, 312 
Examining child, 14 

points to be observed in, 17 
External hydrocephalus, 477 
symptoms of, 478 
diagnosis of, 478 
treatment of, 478 



Face, the, 19 

certain markings upon, 20 
Facial paralysis, 524 
False croup, 588 
Fauces in diphtheria, 261 
Favus, 753 

treatment of, 754 
Febrile diarrhea, 117 
Fecal distention in typhlo-peritonitis, 

183 
Feeding, intervals of, 31 

table of intervals, etc., 39 

tubes, 49 
Fever, formula for, 54 
Flatulence and colic. 100 
Flour ball, 45 
Fcetal rickets, 374 
Fomentations, warm, 30 
Fontanelle, 19 

Food, amount required by infant, 39 
Foreign bodies in the trachea, 608 

treatment of, 609 
Formula for alopecia areata, 753 

for castor-oil, 103 

Cheadle's, no 

for cholera infantum, 127 

for chronic bronchitis, 619 
diarrhoea, 139, 140 



762 



INDEX. 



Formula for constipation, 105, 107, 
109, 1 10, in 

for diphtheria, 272, 273 

for diseases of the stomach, 84 

for febrile diarrhoea, 124 

for lienteric diarrhoea, 136 

for measles, 205 

for ozaena, 586 

for phthisis, 658 

for relaxed throat, 77 

for rickets, 367, 368 

for scabies, 755 

for simple diarrhoea, 117 

for tinea, 749 

for typhlo-peritonitis, 188 

for vomiting, 90 

for whooping-cough, 326 

for worms, 168, 169 
Formulae for lichen urticatus, 731, 732 

for muccus disease, 146, 147, 148 

for scarlet fever, 237-240, etc. 
Functional disease of the liver, 178 
treatment of, 178 

nervous disorders, 543 
Furunculi, 736 

treatment of, 737 



Gangrenous stomatitis or noma, 62 
Gastric ulcer, 91 
Gelatin jelly, 34 
German measles, 244 
Germs of scarlet fever, 229 
Gol ding-Bird's dilator, 279 
Gout, rheumatic, 391 
Gums, lancing of, 54 

H 

Haematuria, 709 

treatment of, 711 
Haemophilia, 437 

symptoms of, 437 

pathology of, 438 

diagnosis of, 438 

prognosis of, 439 

treatment of, 439 
Haemoptysis in whooping cough, 309 
Hare- lip, 69 
Headache, 545 

treatment of, 548 
Head, hydrocephalic, 18 

rickety, 18 



Head, syphilitic, 19 
Heart disease, 681 

variation of normal heart 

sounds, 681 
causes of, 684 

nature of valvular heart dis- 
ease, 685 
acute pericarditis, 687 
endocarditis, 688 
simple dilatation, 689 
prognosis of, 692 
treatment of, 692 
paracentesis of the pericar- 
dium, 695 
malformations of, 696 
symptoms of, 702 
prognosis of, 705 
treatment of, 706 
Hemiatrophia facialis, 525 
symptoms of, 525 
Hemiplegia, 507 
causes of, 507 
morbid anatomy of, 511 
symptoms of, 512 
prognosis of, 513 
treatment of, 513 
Hepatitis, syphilitic, 178 
Herpes, 739 

treatment of, 739 
Histology of tubercular meningitis, 456 
Humanized milk, 42 

analysis of, 42 
Hydrocephalus, 466 
acute, 466 
false, 467 
definition of, 467 
shape of head in, 18, 468 
bones of the skull in, 468 
morbid anatomy of, 468 
causes of, 469 
symptoms of, 472 
diagnosis of, 473 
prognosis of, 474 
treatment of, 476 
tapping in, 476 
external, 477 

symptoms of, 478 
diagnosis of, 478 
treatment of, 478 
Hypertrophy and sclerosis of the brain, 

483 
of the pharyngeal mucous mem- 
brane, 77 



INDEX. 



763 



Hypertrophy of the tongue, 69 
of the tonsils, 74 



Icterus neonatorum, 172 

treatment of, 173 
Idiocy, 548 
Impetigo, 735 

treatment of, 736 
Incubation of diphtheria, 252 
of measles, 193 
of mumps, 295 
of rotheln, 247 
of scarlet fever, 2IO 
of typhoid fever, 33S 
whooping-cough, 301 
varicella, 284 
Infantile convulsions, 535 
symptoms of, 536 
diagnosis of, 537 
results of, 538 
treatment of, 538 
osteo-malacia, 372 
palsy, 490 

symptoms of, 491 
seat of, 493 

morbid anatomy of, 493 
diagnosis of, 501 
prognosis of, 504 
treatment of, 504 
paralysis, 489 
spasm, 592 
syphilis, 416 
Infants' foods, 34 
Inflammation of the dura arachnoid, 

445 
of the cnecal mucous membrane in 
typhlo-peritonitis, 183 
Injections, forced, mode of adminis 

teiing, 158 
Internal strabismus, 525 
Interstitial keratitis in syphilis, 425 
Intestines, diseases of, 93 
Intra-arachnoid hemorrhage, 447 
Intubation for diphtheria, 280 
Intussusception, 148 
pathology of, 149 
morbid anatomy of, 151 
symptoms of, 153 

of strangulation, 154 
diagnosis of, 154 
course and duration, 156 



Intussusception, prognosis, 156 
treatment of, 157 
methods of reducing, 157 
forced injections in, 158 
laparotomy in, 159 
early operation in, 159 
antiseptic precautions in, 160 
table of operations for, 160 
dangers of operation, 161 
chronic, 162 



Jadelot's lines, 20 
Jaundice, 173 

treatment of, 173 



Laparotomy in intussusception, 159 

Laryngismus stridulus, 590 

symptoms of, 594 

prognosis of, 596 

treatment of, 596 

Laryngitis, in syphilis, 419 

spasmodic (false croup), 588 
acute simple, 598 
the voice in, 600 
• diagnosis of, 600 
prognosis of, 601 
treatment of, 601 
chronic, 604 

diagnosis of, 605 
prognosis of, 606 
treatment of, 606 
Late rickets, 369 

symptoms of, 370 
morbid anatomy of, 370 
prognosis of, 373 
treatment of, 373 
Lichen urticatus or strophulus, 728 
diagnosis of, 729 
treatment of, 730 
Liebig's food, 44 

Lienteric diarrhoea [Diarrhee ner 
reuse), 133 
diagnosis of, 134 
treatment of, 135 
Lines of Jadelot's, 20 
Lithaemia, 178 

symptoms of, 178 
treatment of, 179 



764 



INDEX. 



Liver, cirrhosis of, 174 
diseases of, 172 
functional diseases of, 178 
in syphilis, 420 

M 

Malarial fever, 343 

diagnosis of, 344 

prognosis of, 344 

treatment of, 344 
Measles, 193 

incubation of, 193 
prodromal stage of, 194 
eruptive stage of, 195 
temperature of, 195 

chart of, 196 
the pulse in, 197 
bronchial trouble in, 197 
modifications in, 198 
complications and sequelae of, 198 
cough in, 197 

broncho- pneumonia in, 199 
membranous laryngitis in, 199 
diarrhoea in, 199 
noma in, 200 

ulcerative stomatitis following, 200 
etiology of, 20 1 
isolation in, 202 
morbid anatomy of, 202 
micrococci of, 203 
diagnosis of, 204 
treatment of, 204 
diet in, 205 
baths in, 206 
ophthalmia in, 208 
ear discharge in, 208 
Mellin's food, 45 
Melaena neonatorum, 94 
Meningeal hemorrhage, 485 
Meningitis, simple, 447 
symptoms of, 448 
diagnosis from tubercular, 45 1 
prognosis of, 453 
treatment of, 454 
rheumatic, 377 
tubercular, 455 

synonyms of, 455 

histology of, 455 

symptoms of, 458 

temperature chart of, 462 

temperature of, 463 

diagnosis of, 463 



Meningitis, tubercular, prognosis of, 

465 
treatment of, 465 
Micrococcus of diphtheria, 265 

scarlet fever, 230 
Microscopical changes found in scarlet 

fever, 231 
Milk, mother's, 31 

method of regulating flow, 32 
cow's, 33 

specific gravity of, 23 
condensed, 35 
fresh, 36 
sterilization of, 36 
sterilized, the uses of, 39 
peptonized, 40 
humanized, 42 
powder, peptogenic, 42 
human, specific gravity of, 44 
teeth, eruption of, 51 
Modifications in whooping-cough, 309 
Molluscum contagiosum, 746 
Morbid anatomy of atelectasis, 644 
of bronchiectasis, 620 
of chorea, 564 
of chronic bronchitis, 618 
of cretinism, 552 
of diphtheria, 261 
of diseases of the spleen, 432 
of encephalic tumors, 480 
of gangrenous stomatitis, 63 
of hemiplegia, 51 1 
of hydrocephalus, 468 
of infantile paralysis, 493 
of intussusception, 15 1 
of late rickets, 370 
of lienteric diarrhoea, 133 
of measles, 202 
of mumps, 298 
of pertussis, 316 
of phthisis, 651 
of pleurisy, 668 
of pneumonia, 625 
of pseudo-hypertrophic pa- 
ralysis, 514 
of rickets, 358 
of scarlet fever, 230 
of tabes mesenterica, 412 
of typhoid fever, 334 
of whooping-cough, 316 
Morbilli (see Measles), 193 
Mortality of pneumonia, 623 

of whooping-cough, 307 



INDEX. 



765 



Mouth, ulceration of, 67 
wash for thrush, 62 

Muco-enteritis, 116 

Mucous disease, 142 

symptoms of, 143 
diagnosis of, 145 
treatment of, 145 

Mumps, 295 

etiology of, 295 
incubation of, 295 
symptoms of, 296 
temperature, 296 
complications of, 297 
sequelae of, 298 
morbid anatomy of, 298 
diagnosis of, 299 
treatment of, 299 

Mutton broth, 45 



N 

Natiform skull, 19 

Nature of valvular diseases, 685 

Nematodes, 162 

Nephritis, acute, 716. (For treatment, 

see Scarlatinal Dropsy.) 
Nestle's food, 44 
Neuroses, abdominal, 141 
New growths of the kidneys, 720 

treatment for, 721 
Nightmare, 542 

treatment of, 543 
Nocturnal incontinence of the urine, 

721 
Noma, 62, 726 

in measles, 200 
Nurse, wet-, 43 
Nursing-bottle, graduated, 49 
Nursings, intervals of, 31 
Nystagmus, 526 



(Esophagus, the, 80 
O'idium albicans, 59 
Ophthalmia in measles, 208 
Opium, precautions in using, 27 
Orchitis during mumps, 301 

treatment of, 301 
Osteo- arthritis, 391 

malacia, infantile, 372 
Oxyuris vermicularis, 162 



Oxyuris vermicularis, symptoms of, 165 
diagnosis of, 165 
treatment of, 167 
Ozajna, 585 

treatment of, 585 



Pachymeningitis, 447 
Paracentesis in ascites, 191 

of the pericardium, 695 
Paralysis, diphtheritic, 260 
Parker's automatic retractor, 279 
Parotitis, 295 

etiology of, 295 

incubation of, 295 

symptoms of, 296 

temperature of, 296 

complications of, 297 

sequelae of, 298 

morbid anatomy of, 298 

diagnosis of, 299 

treatment of, 299 
Pathology of acute tuberculosis, 393 

of diphtheria, 263 

of haemophilia, 438 

of intussusception, 149 

of pertussis, 312 

of purpura, 436 

of rickets, 362 

of whooping-cough, 312 
Pediculi, 755 

treatment of, 755 
Pemphigus, 740 

diagnosis of, 742 

prognosis of, 742 

treatment of, 742 
Peptogenic milk powder, 42 
Peptonized milk, 40 
Percussion, 22, 580 
Peritoneal abscess, 188 
Peritonitis, 179 

causes of, 179 

symptoms of, 180 

diagnosis of, l8t 

prognosis of, 181 

treatment of, 181 
Perityphlitis, 184 
Pertussis, 301 

incubation of, 301 

symptoms of, 303 

catarrhal stage of, 303 

spasmodic stage of, 304 



766 



INDEX. 



Pertussis, eyes in, 304 

chest in, 304 

nature of whoop, 305 

ulceration of the frsenum linguae 
in, 307 

duration of, 307 

age at which it most frequently 
occurs, 307 

mortality of, 307 

cause of death in, 308 

modifications of, 309 

complications of, 309 

epistaxis in, 309 

haemoptysis in, 309 

convulsions in, 309 

broncho-pneumonia in, 310 

pleurisy in, 310 

sequelae, 311 

atelectasis in, 311 

phthisis in, 312 

etiology of, 312 

pathology of, 312 

epidemics of, 313 

morbid anatomy of, 316 

diagnosis of, 317 

prognosis of, 318 

treatment of, 320 
Peyer's patches in typhoid fever, 334 
Pharyngeal mucous membrane, hyper- 
trophy of, 77 
Pharyngitis, 70 
Phthisis, 648 

symptoms of, 650 

morbid anatomy of, 651 

complications of, 655 

diagnosis of, 655 

prognosis, 656 

treatment, 657 

bronchial, 404 

symptoms, 406 
diagnosis, 407 
prognosis, 408 
treatment, 408 
Physical signs of pneumonia, 632 
Pleurisy, 659 

causes of, 660 

symptoms of, 661 

morbid anatomy of, 668 

complications of, 668 

diagnosis of, 669 

prognosis of, 671 

treatment of, 671 
Pneumonia, 622 



Pneumonia, mortality of, 623 

morbid anatomy of, 625 

causes of, 629 

symptoms of, 629 

temperature chart of, 632 

physical signs, 632 

complications of, 636 

diagnosis of, 636 

prognosis, 637 

results of, 637 

treatment of, 638 

chronic, 639 
Polypus, rectal, 148 
Polyuria, 712 
Poultices, 30 
Prodromal stage of measles, 194 

of scarlet fever, 211 
Prognosis of acute bronchitis, 616 

of acute tuberculosis, 397 

of anaemia, 443 

of atelectasis, 646 

of bronchiectasis, 622 

of cerebral hemorrhage, 487 

of cholera infantum, 127 

of chorea, 573 

of chronic bronchitis, 618 

of laryngitis, 606 

of cretinism, 553 

of diphtheria, 254 

of encephalic tumors, 482 

of enlargement of the spleen, 433 

of epilepsy, 541 

of febrile diarrhoea, 120 

of haemophilia, 439 

of heart disease, 692 

of hemiplegia, 513 

of hydrocephalus, 474 

of infantile convulsions, 538 
palsy, 504 

of intussusception, 156 

of laryngismus stridulus, 596 

of laryngitis, 601 

of late rickets, 373 

of lienteric diarrhoea, 135 

of malarial fever, 344 

of malformations of the heart, 

70S 
of pemphigus, 742 
of peritonitis, 1 81 
of pertussis, 318 
• of phthisis, 656 
of pleurisy, 671 
of pneumonia, 637 



INDEX. 



767 



I'rognosis of pseudohypertrophic pa- 
ralysis, 519 
of retro-pharyngeal abscess, 80 
of rickets, 364 
of scarlet fever, 325 
of scurvy, 442 
of simple meningitis, 453 
of spastic paralysis, 534 
of syphilis, 426 
of syphilitic hepatitis, 177 
of tabes mesenterica, 413 
of tinea, 747 

of tubercular meningitis, 465 
Progressive muscular atrophy, 519 

diagnosis, 524 
Prolapsus ani, 136 
Pseudo-croup, 588 

causes of, 589 
diagnosis of, 589 
treatment of, 590 
hypertrophic paralysis, 514 

morbid anatomy, 514 
diagnosis, 519 
prognosis, 519 
Psoriasis, 743 

treatment of, 743 
Pulse in measles, 197 
in scarlet fever, 212 
the, 23 
Purpura, 434 

symptoms of, 435 

pathology of, 436 

treatment of, 437 

Pyrexia in diphtheria, 253 

Pyuria, 713 

treatment of, 714 



Quantity of milk taken by a child, 39 
Quarantine in scarlatina 229 



Rectal polypus, 148 

treatment of, 148 
Reflex spasm, 593 

vomiting, 90 
Relaxed throat, 76 
Renal calculus, 715 

treatment of, 716 

tumors, 717 
Respiration, 24 
Respiratory organs, diseases of, 579 



Retro pharyngeal abscess, 78 
Rheumatic gout, 391 
Rheumatism, 374 

temperature in, 375 

symptoms of, 375 

acute pericarditis in, 376 

pleurisy in, 376 

endocarditis in, 376 

meningitis in, 377 

diagnosis of, 384 

scarlatinal, 387 

treatment of, 387 
Rickets, 345 

etiology of, 345 

causes of, 346 

time of life of, 347 

symptoms of, 349 

the head in, 349 

craniotabes as a sign of, 351 

zonular cataract in, 357 

lymphatic glands in, 357 

dentition in, 357 

complications of, 358 

morbid anatomy of, 358 

the blood in, 361 

pathology of, 362 

diagnosis of, 363 

prognosis of, 364 

treatment of, 365 

diet in, 365 

late, 369 

foetal, 374 
Roseola, 249 

character of rash, 249 

diagnosis of, 249 

treatment of, 251 
Rotheln, 244 

definition of, 246 

symptoms of, 246 

incubation of, 247 

eruptive stage of, 247 

temperature of, 248 

diagnosis of, 248 

treatment of, 249 
Rougeole anomale, 198 
Round worm, treatment of, 168 
Rubella, 244 



Scarlatina, 209 

mortality of, 210 
incubation of, 210 
prodromal stage of, 21 1 



768 



INDEX. 



Scarlatina, eruptive stage of, 211 

the rash of, 211 

pulse in, 212 

sore throat in, 212 

strawberry tongue in, 212 

temperature of, 212 

desquamation in, 213 

modifications of, 213 

subdivisions of, 213 

temperature, chart of, 215 

complications of, 215 

surgical, 216 

sequelae of, 219 

dropsy in, 219 

albuminuria in, 219 

cardiac disturbance in, 220 

character of urine in, 221 

empyema in, 226 

suppurative pericarditis in, 226 

glandular abscess of neck in, 226 

otitis in, 227 

rheumatism in, 227 

synovitis in, 227 

etiology of, 228 

germs of, 229 

quarantine in, 229 

disinfection of clothing in, 229 

morbid anatomy of, 230 

micrococci in, 230 

microscopical changes found in, 
231 

cancrum oris after, 234 

diagnosis of, 234 

from measles, 235 
from rotheln, 235 
from tonsillitis, 235 
from roseola, 235 

prognosis of, 235 

treatment of, 235 

diet in, 237 

preventive treatment of, 243 
Sclerema neonatorum, 744 
Scrofula, 397 

characteristics of, 402 

treatment of, 402 
Scrofulous habit, 398 

kidney, 714 

treatment of, 714 
Scurvy, 439 

diagnosis of, 442 

prognosis of, 442 

treatment of, 442 
Seborrhcea, 745 



Second dentition, 54 
Sequelae of diphtheria, 259 
of measles, 198 
of mumps, 298 
of pertussis, 311 
of scarlatina, 219 
of syphilis, 425 
of varicella, 289 
of whooping-cough, 31 
Simple diarrhoea, 116 

symptoms of, 116 
meningitis, 447 

symptoms of, 448 
diagnosis of, 450 
prognosis of, 453 
treatment of, 454 
wasting or atrophy, 96 
Skull in craniotabes, 353 
Sleep, 26 

Softening of the stomach. 92 
Spasmodic laryngitis, 588 
Spastic paralysis, 529 

diagnosis of, 529 
prognosis of, 534 
treatment of, 534 
Specific gravity of cow's milk, 23 

of human milk, 44 
Spinach stool, 95 
Spleen, diseases of, 431 
causes of, 43 1 
morbid anatomy of, 432 
enlargement of, 432 
symptoms of, 433 
diagnosis of, 433 
prognosis of, 433 
treatment of, 434 
Status rheumaticus, 378 
Sterilization of milk, 36 
Sterilizer, Starr's, 37 
Sterilizing milk, method of, 38 
Stiff neck, 383 
Stomach, diseases of, 81 
Stomatitis, 56 

Strangulation in intussusception, 154 
Strawberry tongue, 212 
Strippings, 40 

Suffocation in diphtheria, 258 
Sulphur in the treatment of pertussis,32 1 
Surgical scarlatina, 216 
Symptoms of abdominal neuroses, 141 
of acute bronchitis, 613 
of atelectasis, 643 
of bronchial phthisis, 406 



INDEX. 



769 



Symptoms of cerebral hemorrhage, 486 

of cholera infantum, 125 

of cirrhosis of the liver, 175 

of diphtheria, 252 

of encephalic tumor, 479 

of enlargement of the spleen, 433 

of epilepsy, 540 

of febrile diarrhoea, 119 

of gastric ulcer, 92 

of hemophilia, 437 

of heart disease, 690 

of hemiatrophia facialis, 525 

of hemiplegia, 512 

of hydrocephalus, 472 

of hypertrophy of the pharyngeal 
mucous membrane, 78 

of infantile convulsions, 536 

of infantile palsy, 491 

of intussusception, 153 

of laryngismus, 594 

of late rickets, 370 

of lienteric diarrhoea, 133 

of malformation of the heart, 702 

of mucous disease, 143 

of parotitis, 296 

of peritonitis, 180 

of pertussis, 303 

of phthisis, 650 

of pleurisy, 661 

of pneumonia, 629 

of purpura, 435 

of retro-pharyngeal abscess, 79 

of rheumatism, 375 

of rickets, 349 

of rotheln, 246 

of simple diarrhoea, 116 

of strangulation in intussuscep- 
tion, 154 

of syphilis, 417 

of syphilitic hepatitis, 177 

of tabes mesenterica, 409 

of thrombosis of the cerebral 
sinuses, 488 

of tubercular meningitis, 458 

of tuberculosis, 395 

of typhlo-peritonitis, 182 

of typhoid fever, 328 

of vaccinia, 291 

of varicella, 284 

of whooping-cough, 303 

of worms, 165 
Syphilis, 416 

symptoms of, 417 



Syphilis, appearance of child in, 417 
cafe-au-lait tint of face in, 418 
rash in, 418 
laryngitis in, 419 
enlarged spleen in, 420 

liver in, 420 
cranial bones in, 420 
pseudo-paralysis in, 423 
ulceration of the tongue in, 423 
sequela; of, 425 
interstitial keratitis in, 425 
contagion of, 426 
diagnosis of, 426 
prognosis of, 426 
treatment of, 427 
Syphilitic hepatitis, 1 75 

symptoms of, 177 

diagnosis of, 177 

prognosis of, 177 

treatment of, 177 



Tabes mesenterica, 40S 

symptoms of, 409 
morbid anatomy of, 412 
diagnosis of, 412 
prognosis of, 413 
treatment of, 414 
Table of ages in varicella. 285 

of opera' ions for intussusception, 
160 
Tache cerebrale, 451 
Tenia mediocanellata, 162 

solium, 162 
Tanret's pelletierine, 171 
Tapeworm, 162 

treatment of, 169 
Teeth, milk, 51 

Temperature chart of catarrhal pneu- 
monia, 635 
of croupous pneumonia, 632 
of measles, 196 
of scarlatina, 215 
of tubercular meningitis, 462 
of typhoid fever, 332 
of vaccinia, 292 
of varicella, 283 
method of taking, 16 
of diphtheria, 253 
of measles, 195 
of mumps, 296 
of parotitis, 296 



770 



INDEX. 



Temperature of rheumatism, 375 

of rotheln, 248 

of scarlatina, 212 

of typhoid fever, 330 
Thermometer, method of using, 16 
Thread worms, 162 

treatment of, 167 
Throat, relaxed, 76 
Thrombosis of the cerebral sinuses, 
488 
symptoms of, 488 
treatment of, 489 
Thrush, 59 

complications of, 61 

treatment of, 62 
Tinea, 746 

diagnosis of, 747 

prognosis of, 747 

treatment of, 748 
Tongue, hypertrophy of, 69 
Tonsillitis, acute, 71 

chronic, 74 

treatment of, 75 
Tonsils, hypertrophy of, 74 
Torticollis, 528 

treatment of, 528 
Tracheotomy for diphtheria, 275 
rules for operation, 278 

care of tube in, 279 

for foreign bodies in trachea, 
610 
Treatment of acute bronchitis, 616 
tuberculosis, 397 
urticaria, 732 

of alopecia areata, 753 

of anaemia, 443 

of anuria, 712 

of aphthous stomatitis, 57 

of ascites, 191 

of atelectasis, 647 

of bromide eruption, 738 

of bronchiectasis, 622 

of bronchial phthisis, 408 

of catarrhal stomatitis, 56 

of cerebral hemorrhage, 487 

of cholera infantum, 127 

of chorea, 574 
magna, 556 

of chronic bronchitis, 619 
diarrhoea, 137 
laryngitis, 606 

of constipation, 105 

of cretinism, 553 



Treatment of diphtheria, 269 

of diphtheritic paralysis, 281 

of diseases of the stomach, 83 

of dysentery, 141 

of dysuria, 712 

of eczema, 733 

of encephalic tumors, 482 

of enlarged spleen, 434 

of enuresis, 723 

of epilepsy, 541 

of epistaxis, 588 

of erythema, 744 

of favus, 754 

of febrile diarrhoea, 120 

of flatulence and colic, 101 

of foreign bodies in the trachea, 

609 
of furunculi (boils), 737 
of gangrenous stomatitis, 65 
of gastric ulcer, 92 
of haematuria, 71 1 
of haemophilia, 439 
of headache, 548 
of heart disease, 692 
of hemiplegia, 513 
of herpes, 739 
of hydrocephalus, 476 
of hypertrophy of the pha- 
ryngeal mucous membrane, 

78 
of icterus neonatorum, 173 
of impetigo, 736 
of infantile convulsions, 538 

palsy, 504 
of intussusception, 157 
of jaundice, 173 
of laryngismus stridulus, 596 
of laryngitis? 601 
of late rickets, 373 
of lichen urticatus, 730 
of lienteric diarrhoea, 135 
of lithaemia, 179 
of malarial fever, 344 
of malformations of the heart, 

706 
of measles, 204 
of mucous disease, 145 
of mumps, 299 
of new growths of the kidney, 

721 
of nightmare, 543 
of orchitis after mumps, 301 
of ozaena, 585 



INDEX. 



771 



Treatment of pediculi, 755 
of pemphigus, 742 
of peritoneal abscess, 189 
of peritonitis, 181 
of pertussis, 320 
of phthisis, 657 
of pleurisy, 671 
of pneumonia, 638 
of prolapsus ani, 136 
of pseudo-croup, 590 
of psoriasis, 743 
of purpura, 437 
of pyuria, 714 
of relaxed throat, 77 
of renal calculus, 716 
of retro-pharyngeal abscess, 80 
of rheumatism, 387 
of rickets, 365 
of roseola, 251 
of rotheln, 249 
of round worms, 168 
of scabies, 754 
of scarlatina, 235 
of scarlatinal nephritis, 240 
of scrofula, 402 
of scrofulous kidney, 714 
of scurvy, 442 
of seborrhea, 745 
of simple atrophy, 98 

diarrhoea, 116 

meningitis, 454 
of syphilis, 427 
of syphilitic hepatitis, 1 77 
of tabes mesenterica, 114 
of tapeworm, 169 
of thread worms, 167 
of thrombosis of the cerebral 

sinuses, 489 
of thrush, 62 
of tinea, 748 
of tonsillitis, 75 
of torticollis, 528 
of tubercular meningitis, 465 
of tuberculosis, 397 
of typhlo-peritonitis, 186 
of typhoid fever, 339 
of ulceration of the mouth, 68 
of ulcerative stomatitis, 58 
of vaginal discharges, 726 
of varicella, 289 
of vomiting, 87 

of warty growths in the larynx , 607 
of worms, 167 



Trochisques Vichot in pertussis, 321 
Tubercular disease of the liver, 174 
meningitis, 455 

synonyms of, 455 

histology of, 456 

symptoms of, 458 

temperature chart of, 462 
in, 463 

diagnosis of, 463 

prognosis of, 465 

treatment of, 465 
peritonitis, 408 
ulceration of the stomach, 92 
Tuberculosis, acute, 393 

pathology of, 393 

symptoms of, 395 

diagnosis of, 396 

prognosis, 397 

treatment, 397 
Typhlitis, 184 
Typhlo-peritonitis, 181 

causes of, 182 

symptoms of, 182 

facial distention in, 183 

inflammation of the caecal 
mucous membrane in, 1S3 

diagnosis of, 185 

prognosis, 185 

treatment, 186 
Typhoid fever, 328 

symptoms of, 328 

headache in, 329 

vomiting in, 329 

diarrhoea in, 329 

remittent type of, 329 

temperature in, 330 

delirium in, 331 

temperature chart of, 332 

rose spots of, 333 

splenic enlargement in, 333 

tongue in, 333 

duration of, 333 

morbid anatomy of, 334 

Peyer's patches in, 334 

diagnosis from tuberculosis, 

from meningitis, 336 
from ulcerative endo- 
carditis, 338 
from ostitic pyaemia, 33S 

incubation of, 338 

treatment of, 339 

diet in, 339 



772 



INDEX. 



U 

Ulceration of the fraenum linguae in 

pertussis, 68 
Ulceration of the mouth, 67 
Ulcerative stomatitis, 57 
Ulcer of stomach, 91 
Urine, character of, in diphtheria, 254 
in scarlatina, 221 
in urticaria, 732 
Uvula in diphtheria, 261 



Vaccination, 292 

modes of introducing virus, 292 

kinds of virus employed, 293 

scarification in, 293 

puncture method, 293 

abrasion method, 293 

from arm to arm, 293 

method of preparing the crust, 293 

with bovine virus, 294 

best age for, 294 
Vaccinia, 290 

local symptoms, 290 

course of the sore, 290 

general symptoms of, 291 

temperature chart of, 292 
Vaginal and labial discharges, 726 

treatment of, 726 
Varicella, 282 

temperature chart of, 283 

incubation of, 284 

eruptive stage of, 284 

table of ages in, 285 

gangrenosa, 286 

diagnosis of, 287 

from variola, 287 

persistent or relapsing, 288 

sequelae, 289 

prurigo, 289 

treatment of, 289 
Veal broth, 45 
Vomiting, 85 

W 

Warty growths in the larynx, 607 

treatment of, 607 
Wet-nurse, 43 

selection of, 43 
Whooping-cough, 301 



Whooping-cough, incubation of, 30 

symptoms of, 303 

catarrhal stage of, 303 

spasmodic stage of, 304 

eyes in, 304 

chest in, 304 

nature of whoop, 305 

ulceration of the fraenum 
linguae, 307 

duration of, 307 

the age at which it most often 
occurs, 307 

mortality of, 307 

cause of death, 308 

modifications in, 309 

complications, 309 

epistaxis in, 309 

haemoptysis in, 309 

convulsions in, 309 

broncho-pneumonia in, 310 

pleurisy in, 310 

sequelae, 311 

atelectasis in, 311 

phthisis in, 312 

etiology of, 312 

pathology of, 312 

epidemics of, 313 

morbid anatomy of, 316 

diagnosis of, 317 

prognosis of, 318 

treatment of, 320 
Worms, 162 

varieties, 162 
seat, 162 

habitat of, 162 

description of, 162 
round, 163 

description of, 163 

habitat of, 163 
tape, 163 

description of, 164 

symptoms of, 165 

diagnosis of, 165 

treatment of, 167 



X 



Xanthelasma, 746 



Zonular cataract in rickets, 357 



CATALOGUE No. 7. 



NOVEMBER, 1889. 



A CATALOGUE 

OF 

Books for Students. 



INCLUDING THE 



PQUIZ-COMPENDS? 





CONTENTS. 






PAGE 




PAGE 


New Series of Manuals 


, 2,3.4,5 


Obstetrics. . 


. IO 


Anatomy, 




6 


Pathology, Histology, 


. n 


Biology, 




ii 


Pharmacy, . 


• J 3 


Chemistry, . 




6 


Physical Diagnosis, 


. ii 


Children's Diseases, 




7 


Physiology, . 


. 12 


Dentistry, 




8 


Practice of Medicine, 


. 12 


Dictionaries, 




8 


Prescription Books, 


. 12 


Eye Diseases, 
Electricity, . 




8 


PQuiz-Compends ? 


• J 5, l6 




9 


Skin Diseases, 


• *3 


Gynaecology, 




10 


Surgery, 


• »3 


Hygiene, 




9 


Therapeutics, 


• 9 


Materia Medica, . 




9 


Throat, 


• *4 


Medical Jurisprudence 




9 


Urine and Urinary Org 


ans, 14 


Miscellaneous, 


PU 


IO 


Venereal Diseases, 


• 14 




BLISJ 


IED BY 





P. BLAKISTON, SON & CO., 

Medical Booksellers, Importers and Publishers. 

LARGE STOCK OF ALL STUDENTS' BOOKS, AT 
THE LOWEST PRICES. 

1012 Walnut Street, Philadelphia. 



*** For sale by all Booksellers, or any book will be sent by mail, 
postpaid, upon receipt of price. Catalogues of books on all branches 
of Medicine, Dentistry, Pharmacy, etc., supplied upon application. 



THE NEW SERIES OF MANUALS. 



No. 5. ORG-ANIC CHEMISTRY. 

Or the Chemistry of the Carbon Compounds. By Prof. 
Victor von Richter, University of Breslau. Au- 
thorized translation, from the Fourth German Edition. 
By Edgar F. Smith, m.a., ph.d. ; Prof, of Chemistry 
in University of Pennsylvania; Member of the Chem. 
Socs. of Berlin and Paris. 

" I must say that this standard treatise is here presented in a 
remarkably compendious shape."— y. W. Holland, m.d., Professor 
of Chemistry , Jefferson Medical College, Philadelphia. 

" This work brings the whole matter, in simple, plain language, 
to the student in a clear, comprehensive manner. The whole 
method of the work is one that is mOre readily grasped than that of 
older and more famed text-books, and we look forward to the time 
when, to a great extent, this work will supersede others, on the 
score of its better adaptation to the wants of both teacher and 
student." — Pharmaceutical Record. 

" Prof, von Richter's work has the merit of being singularly 
clear, well arranged, and for its bulk, comprehensive. Hence, it 
will, as we find it intimated in the preface, prove useful not merely 
as a text-book, but as a manual of reference." — The Chemical 

News, London. 



No. 6. DISEASES OP CHILDREN. 

A Manual. By J. F. Goodhart, m.d., Phys. to the 
Evelina Hospital for Children ; Asst. Phys. to 
Guy's Hospital, London. American Edition. Edited 
by Louis Starr, m.d., Clinical Prof, of Dis. of 
Children in the Hospital of the Univ. of Pennsylvania, 
and Physician to the Children's Hospital, Phila. 
Containing many new Prescriptions, a list of over 50 
Formulae, conforming to the U. S. Pharmacopoeia, and 
Directions for making Artificial Human Milk, for the 
Artificial Digestion of Milk, etc. 

" The author has avoided the not uncommon error of writing a 
book on general medicine and labeling it ' Diseases of Children,' 
but has steadily kept in view the diseases which seemed to be 
incidental to childhood, or such points in disease as appear to be so 
peculiar to or pronounced in children as to justify insistence upon 
them. * * * A safe and reliable guide, and in many ways 
admirably adapted to the wants of the student and practitioner." — 
American Journal of Medical Science. 

Price of each Book, Cloth, $3.00 ; Leather, $3.50. 



THE NEW SERIES OF MANUALS. 



No. 6. Goodhart and Starr : — Continued. 

** Thoroughly individual, original and earnest, the work evi- 
dently of a close observer and an independent thinker, this book, 
though small, as a handbook or compendium is by no means made 
up of bare outlines or standard facts." — The Therapeutic Ga- 
zette. 

"As it is said of some men, so it might be said of some books, 
that they are 'born to greatness.' This new volume has, we 
believe, a mission, particularly in the hands of the younger 
members of the profession. In these days of prolixity in medical 
literature, it is refreshing to meet with an author who knows both 
what to say and when he has said it. The work of Dr. Goodhart 
(admirably conformed, by Dr. Starr, to meet American require- 
ments) is the nearest approach to clinical teaching without the 
actual presence of clinical material that we have yet seen." — New 
York Medical Record. 



No. 7. PRACTICAL THERAPEUTICS. 

FOURTH EDITION, WITH AN INDEX OF DISEASES. 

Practical Therapeutics, considered with reference to 
Articles of the Materia Medica. Containing, also, an 
Index of Diseases, with a list of the Medicines 
applicable as Remedies. By Edward John Waring, 
m.d., f.r.c.p. Fourth Edition. Rewritten and Re- 
vised. By Dudley W. Buxton, m.d., Asst. to the 
Prof, of Medicine at University College Hospital. 

" We wish a copy could be put in the hands of every Student or 
Practitioner in the country. In our estimation, it is the best book 
of the kind ever written." — N. Y. Medical Journal. 

No. 8. MEDICAL JURISPRUDENCE AND 
TOXICOLOGY. 

NEW, REVISED AND ENLARGED EDITION. 

By John J. Reese, M.D., Professor of Medical Jurispru- 
dence and Toxicology in the University of Pennsyl- 
vania ; President of the Medical Jurisprudence Society 
of Phila. ; 2d Edition, Revised and Enlarged. 

"This admirable text-book." — Amer.Jour. of Med. Sciences. 

" We lay this volume aside, after a careful perusal of its pages, 
with the profound impression that it should be in the hands of every 

doctor and lawyer. It fully meets the wants of all students 

He has succeeded in admirably condensing into a handy volume all 
the essential points." — Cincinnati Lancet and Clinic. 

Price of each Book, Cloth, $3,00; Leather, $3.50. 



6 STUDENTS' TEXT-BOOKS AND MANUALS. 

ANATOMY. 

Holden's Anatomy. A manual of Dissection of the Human 

Body. Fifth Edition. Enlarged, with Marginal References and 

over 200 Illustrations. Octavo. Cloth, 5.00; Leather, 6.00 

Bound in Oilcloth, for the Dissecting Room, $4.50. 

" No student of Anatomy can take up this book without being 
pleased and instructed. Its Diagrams are original, striking and 
suggestive, giving more at a glance than pages of text description. 
* * * The text matches the illustrations in directness of prac- 
tical application and clearness of detail." — Ne-w York Medical 
Record. 

Holden's Human Osteology. Comprising a Description of the 
Bones, with Colored Delineations of the Attachments of the 
Muscles. The General and Microscopical Structure of Bone and 
its Development. With Lithographic Plates and Numerous Illus- 
trations. Seventh Edition. 8vo. Cloth, 6.00 

Holden's Landmarks, Medical and Surgical. 4th ed. 

Cloth, 1.25 

Heath's Practical Anatomy. Sixth London Edition. 24 Col- 
ored Plates, and nearly 300 other Illustrations. Cloth, 5.00 

Potter's Compend of Anatdmy. Fourth Edition. 117 Illus- 
trations. Cloth, 1.00; Interleaved for Notes, 1.25 

CHEMISTRY. 

Bartley's Medical Chemistry. Second Edition. A text-book 
prepared specially for Medical, Pharmaceutical and Dental Stu- 
dents. With 50 Illustrations, Plate of Absorption Spectra and 
Glossary of Chemical Terms. Revised and Enlarged. Cloth, 2.50 
*#* This book has been written especially for students and phy- 
sicians. It is practical and concise, dealing only with those parts 
of chemistry and physics pertaining to medicine; no time being 
wasted in long descriptions of substances and theories of interest 
only to the advanced chemical student. 

Bloxam's Chemistry, Inorganic and Organic, with Experiments. 
Seventh Edition. Enlarged and Rewritten. Nearly 300 Illus- 
trations. Cloth, 4.50 ; Leather, 5.50 

Richter's Inorganic Chemistry. A text-book for Students. 
Third American, from Fifth German Edition. Translated by 
Prof. Edgar F. Smith, ph.d. 89 Wood Engravings and Colored 
Plate of Spectra. Cloth, 2.00 

Richter's Organic Chemistry, or Chemistry of the Carbon 
Compounds. Translated by Prof. Edgar F. Smith, ph.d. 
Illustrated. Cloth, 3.00 ; Leather, 3.50 

4SS* See pages 2 to j for list of Students' Manuals. 



STUDENTS' TEXT-BOOKS AND MANUALS. 7 

Chemistry : — Continued. 

Trimble. Practical and Analytical Chemistry. A Course in 
Chemical Analysis, by Henry Trimble, Prof, of Analytical Chem- 
istry in the Phila. College of Pharmacy. Illustrated. Third 
Edition. 8vo. Cloth, 1.50 

Tidy. Modern Chemistry. 2d Ed. Cloth, 5.50 

Leffmann's Compend of Chemistry. Inorganic and Organic. 
Including Urinary Analysis and the Sanitary Examination of 
Water. New Edition. Cloth, 1. 00; Interleaved for Notes, 1.25 

Muter. Practical and Analytical Chemistry. Second Edi- 
tion. Revised and Illustrated. - Cloth, 2.00 

Holland. The Urine, Common Poisons, and Milk Analysis, 
Chemical and Microscopical. For Laboratory Use. 3d 
Edition, Enlarged. Illustrated. Cloth, 1.00 

Van Nuys. Urine Analysis. Illus. Cloth, 2.00 

Wolff's Applied Medical Chemistry. By Lawrence Wolff, 
m.d., Demonstrator of Chemistry in Jefferson Medical College, 
Philadelphia. Cloth, 1.00 

CHILDREN. 

Goodhart and Starr. The Diseases of Children. A Manual 
for Students and Physicians. By J. F. Goodhart, m.d., Physi- 
cian to the Evelina Hospital for Children ; Assistant Physician 
to Guy's Hospital, London. American Edition, Revised and 
Edited by Louis Starr, m.d., Clinical Professor of Diseases of 
Children in the Hospital of the University of Pennsylvania; 
Physician to the Children's Hospital, Philadelphia. Containing 
many new Prescriptions, a List of over 50 Formulae, conforming 
to the U. S. Pharmacopoeia, and Directions for making Arti- 
ficial Human Milk, for the Artificial Digestion of Milk, etc. 

Cloth, 3.00; Leather, 3.50 

Day. On Children. A Practical and Systematic Treatise. 
Second Edition. 8vo. 752 pages. Cloth, 3.00; Leather, 4.00 

Meigs and Pepper. The Diseases of Children. Seventh 
Edition. 8vo. Cloth, 5.00; Leather, 6.00 

Starr. Diseases of the Digestive Organs in Infancy and 
Childhood. With chapters on the Investigation of Disease, 
and on the General Management of Children. By Louis Starr, 
m.d., Clinical Professor of Diseases of Children in the Univer- 
sity of Pennsylvania; with a section on Feeding, including special 
Diet Lists, etc. Illus. Cloth, 2.50 

£Sf See pages 75 and ib for list 0/ ? Quiz- CotnJ>ends f 



8 STUDENTS' TEXT-BOOKS AND MANUALS. 

DENTISTRY. 

Fillebrown. Operative Dentistry. 330 Illustrations. Just 
Ready. Cloth, 2.50 

Flagg's Plastics and Plastic Filling. 3d Ed. Preparing. 

Gorgas. Dental Medicine. A Manual of Materia Medica and 
Therapeutics. Third Edition. Cloth, 3.50 

Harris. Principles and Practice of Dentistry. Including 
Anatomy, Physiology, Pathology, Therapeutics, Dental Surgery 
and Mechanism. Twelfth Edition. Revised and enlarged by 
Professor Gorgas. 1028 Illustrations. Cloth, 7.00; Leather, 8.00 

Richardson's Mechanical Dentistry. Fifth Edition. 569 
Illustrations. 8vo. Cloth, 4.50; Leather, 5.50 

Stocken's Dental Materia Medica. Third Edition. Cloth, 2.50 

Taft's Operative Dentistry. Dental Students and Practitioners. 
Fourth Edition. 100 Illustrations. Cloth, 4.25 ; Leather, 5.00 

Talbot. Irregularities of the Teeth, and their Treatment. 
Illustrated. 8vo. Cloth, 2.00 

Tomes' Dental Anatomy. Third Ed. 191 Illus. Preparing. 

Tomes' Dental Surgery. 3d Edition. Revised. 292 Illus. 
772 Pages. Cloth, 5.00 

DICTIONARIES. 

Cleaveland's Pocket Medical Lexicon. Thirty-first Edition. 

Giving correct Pronunciation and Definition of Terms used in 

Medicine and the Collateral Sciences. Very small pocket size. 

Cloth, red edges .75 ; pocket-book style, 1.00 

Longley's Pocket Dictionary. The Student's Medical Lexicon, 
giving Definition and Pronunciation of all Terms used in Medi- 
cine, with an Appendix giving Poisons and Their Antidotes, 
Abbreviations used in Prescriptions, Metric Scale of Doses, etc. 
241x10. Cloth, 1. 00; pocket-book style, 1.25 

EYE. 

Arlt. Diseases of the Eye. Including those of the Conjunc- 
tiva, Cornea, Sclerotic, Iris and Ciliary Body. By Prof. Von 
Arlt. Translated by Dr. Lyman Ware. Illus. 8vo. Cloth, 2.50 

Hartridge on Refraction. 4th Ed. Cloth, 2.00 

Macnamara. Diseases of the Eye. 4th Edition. Revised. 
Colored Plates and Wood Cuts and Test Types. Cloth, 4.00 

Meyer. Diseases of the Eye. A complete Manual for Stu- 
dents and Physicians. 270 Illustrations and two Colored Plates. 
8vo. Cloth, 4.50; Leather, 5.50 

Fox and Gould. Compend of Diseases of the Eye and 
Refraction. 2d Ed. Enlarged. 71 Illus. 39 Formulae. 

Cloth, 1. 00 ; Interleaved for Notes, 1.25 

4®=- See pages 2 to 5 for list of Students' Manuals. 



STUDENTS' TEXT-BOOKS AND MANUALS. 



ELECTRICITY. 

Mason's Compend of Medical and Surgical Electricity. 
With numerous Illustrations. i2mo. Cloth, i.oo 

HYGIENE. 

Parkes' (Ed. A.) Practical Hygiene. Seventh Edition, en- 
larged. Illustrated. 8vo. Cloth, 4.50 

Parkes' (L. C.) Manual of Hygiene and Public Health. 
i2mo. Cloth, 2.50 

Wilson's Handbook of Hygiene and Sanitary Science. 
Sixth Edition. Revised and Illustrated. Cloth, 2.75 

MATERIA MEDICA AND THERAPEUTICS. 

Potter's Compend of Materia Medica, Therapeutics and 

Prescription Writing. Fifth Edition, revised and improved. 

Cloth, 1.00; Interleaved for Notes, 1.25 

Biddle's Materia Medica. Eleventh Edition. By the late 
John B. Biddle, m.d., Professor of Materia Medica in Jefferson 
Medical College, Philadelphia. Thoroughly revised, and in many 
parts rewritten, by his son, Clement Biddle, m.d., Assistant 
Surgeon, U. S. Navy, assisted by Henry Morris, m.d., Demon- 
strator of Obstetrics in Jefferson Medical College. 8vo., illus- 
trated. Cloth, 4.25; Leather, 5.00 

Headland's Action of Medicines. 9th Ed. 8vo. Cloth, 3.00 

Potter. Materia Medica, Pharmacy and Therapeutics. 
Including Action of Medicines, Special Therapeutics, Pharma- 
cology, etc. Second Edition. Cloth, 4.00; Leather, 5 00 

Starr, Walker and Powell. Synopsis of Physiological 
Action of Medicines, based upon Prof. H. C. Wood's " Materia 
Medica and Therapeutics." 3d Ed. Enlarged. Cloth, .75 

Waring. Therapeutics. With an Index of Diseases and an 
Index of Remedies. A Practical Manual. Fourth Edition. 
Revised and Enlarged. Cloth, 3.00; Leather, 3.50 

MEDICAL JURISPRUDENCE. 

Reese. A Text-book of Medical Jurisprudehce and Toxi- 
cology. By John J. Reese, m.d., Professor of Medical Juris- 
prudence and Toxicology in the Medical Department of the 
University of Pennsylvania; President of the Medical Juris- 
prudence Society of Philadelphia; Physician to St. Joseph's 
Hospital ; Corresponding Member of The New York Medico- 
legal Society. 2d Edition. Cloth, 3.00 ; Leather, 3.50 

Woodman and Tidy's Medical Jurisprudence and Toxi- 
cology. Chromo-Lithographic Plates and 116 Wood engravings. 

Cloth, 7.50; Leather, 8.50 

i8Sf* See pages Ij and lb for list of ? Quiz-Compenrfs ? 



10 STUDENTS' TEXT-BOOKS AND MANUALS. 



MISCELLANEOUS. 

Allingham. Diseases of the Rectum. Fourth Edition. Illus- 
trated. 8vo. Paper covers, .75 ; Cloth, 1.25 

Beale. Slight Ailments. Their Nature and Treatment. Illus- 
trated. 8vo. Cloth, 1.25 
Domville on Nursing. 6th Edition. Cloth, .75 

Fothergill. Diseases of the Heart; and Their Treatment. 
Second Edition. 8vo. Cloth, 3.50 

Gowers. Diseases of the Nervous System. 341 Illus- 
trations. Cloth, 6.50; Leather, 7.50 

Mann's Manual of Psychological Medicine, and Allied Ner- 
vous Diseases. Their Diagnosis, Pathology and Treatment, and 
their Medico-Legal Aspects. Illus. Cloth, 5.00 ; Leather, 6.00 

Tanner. Memoranda of Poisons. Their Antidotes and Tests. 
Sixth Edition. Revised by Henry Leffmann, m.d. Cloth, .75 

Parvin. Lectures on Obstetric Nursing. 32mo. Cloth, .75 
OBSTETRICS AND GYNAECOLOGY. 

Byford. Diseases of Women. The Practice of Medicine and 
Surgery, as applied to the Diseases and Accidents Incident to 
Women. By W. H. Byford, a.m., m.d., Professor of Gynaecology 
in Rush Medical College and of Obstetrics in the Woman's Med- 
ical College, etc., and Henry T. Byford, m.d., Surgeon to the 
Woman's Hospital of Chicago ; Gynaecologist to St Luke's 
Hospital, etc. Fourth Edition. Revised, Rewritten and En- 
larged. With 306 Illustrations, over 100 of which are original. 
Octavo. 832 pages. Cloth, 5.00 ; Leather, 6.00 

Cazeaux and Tarnier's Midwifery. With Appendix, by 
Munde. The Theory and Practice of Obstetrics ; including the 
Diseases of Pregnancy and Parturition, Obstetrical Operations, 
etc. By P. Cazeaux. Remodeled and rearranged, with revi- 
sions and additions, by S. Tarnier, m.d , Professor of Obstetrics 
and Diseases of Women and Children in the Faculty of Medicine 
of Paris. Eighth American, from the Eighth French and First 
Italian Edition. Edited by Robert J. Hess, m.d., Physician to 
the Northern Dispensary, Philadelphia, with an appendix by 
Paul F. Munde, m.d., Professor of Gynaecology at the N. Y. 
Polyclinic. Illustrated by Chromo-Lithographs, Lithographs, 
and other Full^page Plates, seven of which are beautifully colored, 
and numerous Wood Engravings. Students' Edition. One 
Vol., 8vo. Cloth, 5.00; Leather, 6.00 

Lewers' Diseases of Women. A Practical Text-Book. 139 
Illustrations. Cloth, 2.25 

Parvin's Winckel's Diseases of Women. Edited by Prof. 
Theophilus Parvin, Jefferson Medical College, Philadelphia. 
150 Illustrations. Second Edition, Revised and Enlarged. See 
page 3. Cloth, 3.00; Leather, 3.50 

Morris. Compend of Gynecology. Illustrated. In Press. 

40^=* See pages 2 to 5 for list of New Manuals. 



STUDENTS' TEXT-BOOKS AND MANUALS. 11 

Obstetrics and Gynecology : — Continued. 

Winckel's Obstetrics. A Text-book on Midwifery, includ- 
ing the Diseases of Childbed. By Dr. F. Winckel, Professor 
of Gynaecology, and Director of the Royal University Clinic for 
Women, in Munich. Authorized Translation, by J. Clifton 
Edgar, m.d., Lecturer on Obstetrics, University Medical Col- 
lege, New York, with nearly 200 handsome illustrations, the 
majority of which are original with this work. Octavo. In press. 

Landis' Compend of Obstetrics. Illustrated. 4th edition, 
enlarged. Cloth, 1.00 ; Interleaved for Notes, 1.25 

Galabin's Midwifery. A New Manual for Students. By A. 
Lewis Galabin, m.d., f.k.c.p., Obstetric Physician to Guy's 
Hospital, London, and Professor of Obstetrics in the same Insti- 
tution. 227 Illustrations. See page j. Cloth, 3.00; Leather, 3.50 

Glisan's Modern Midwifery. 2d Edition. Cloth, 3.00 

Rigby's Obstetric Memoranda. By Alfred Meadows, 'm.d. 
4th Edition. Cloth, .50 

Meadows' Manual of Midwifery. Including the Signs and 
Symptoms of Pregnancy, Obstetric Operations, Diseases of the 
Puerperal State, etc. 145 Illustrations. 494 pages. Cloth, 2.00 

Swayne's Obstetric Aphorisms. For the use of Students 
commencing Midwifery Practice. 8th Ed. i2mo. Cloth, 1.25 

PATHOLOGY. HISTOLOGY. BIOLOGY. 

Bowlby. Surgical Pathology and Morbid Anatomy, for 
Students. 135 Illustrations. i2mo. Cloth, 2.00 

Davis' Elementary Biology. Illustrated. Cloth, 4.00 

Rindfleisch's General Pathology. By Prof. Edward Rind- 
fleisch. Translated by Wm. H. Mercur, m.d. Edited by James 
Tyson, m.d., Professor of Clinical Medicine in the University 
of Pennsylvania. i2mo. Cloth, 2.00 

Gilliam's Essentials of Pathology. A Handbook for Students. 
47 Illustrations. 12010. Cloth, 2.00 

^The object of this book is to untold to the beginner the funda- 
mentals of pathology in a plain, practical way, and by bringing 
them within easy comprehension to increase his interest in the study 
of the subject. 

Gibbes' Practical Histology and Pathology. Third Edition. 

Enlarged. i2mo. Cloth, 1.75 

Virchow's Post-Mortem Examinations. 2d Ed. Cloth, 1.00 

PHYSICAL DIAGNOSIS. 

Bruen's Physical Diagnosis of the Heart and Lungs. By 
Dr. Edward T. Bruen, Assistant Professor of Clinical Medicine 
in the University of Pennsylvania. Second Edition, revised. 
With new Illustrations. i2mo. Cloth, 1.50 

#g=* See pages 15 and ib for list of ? Quiz- Contends f 



12 STUDENTS' TEXT-BOOKS AND MANUALS. 

PHYSIOLOGY. 

Yeo's Physiology. Fourth Edition. The most Popular Stu- 
dents' Book. By Gerald F. Yeo, m.d., fjj.c.s., Professor of 
Physiology in King's College, London. Small Octavo. 758 
pages. 321 carefully printed Illustrations. With a Full 
Glossary and Index. See Page 3. Cloth, 3.00; Leather, 3.50 

Brubaker's Compend of Physiology. Illustrated. Fifth 
Edition. Cloth, 1. 00; Interleaved for Notes, 1.25 

Stirling. Practical Physiology, including Chemical and Ex- 
perimental Physiology. 142 Illustrations. Cloth, 2.25 

Kirke's Physiology. New 12th Ed. Thoroughly Revised and 
Enlarged. 502 Illustrations. Cloth, 4.00; Leather, 5.00 

Landois' Human Physiology. Including Histology and Micro- 
scopical Anatomy, and with special reference to Practical Medi- 
cine. Third Edition. Translated and Edited by Prof. Stirling. 
692 Illustrations. Cloth, 6.50; Leather, 7.50 

" With this Text-book at his command, no student could fail in 

his examination." — Lancet. 

Sanderson's Physiological Laboratory. Being Practical Ex- 
ercises for the Student. 350 Illustrations. 8vo. Cloth, 5.00 

Tyson's Cell Doctrine. Its History and Present State. Illus- 
trated. Second Edition. Cloth, 2.00 

PRACTICE. 

Roberts' Practice. New Revised Edition. A Handbook 
of the Theory and Practice of Medicine. By Frederick T. 
Roberts, m.d. ; m.r.c.p., Professor of Clinical Medicine and 
Therapeutics in University College Hospital, London. Seventh 
Edition. Octavo. Cloth, 5.50 ; Sheep, 6.50 

Hughes. Compend of the Practice of Medicine. 3d Ed. 

Two parts, each, Cloth, 1.00; Interleaved for Notes, 1.25 

Part i. — Continued, Eruptive and Periodical Fevers, Diseases 

of the Stomach, Intestines, Peritoneum, Biliary Passages, Liver, 

Kidneys, etc., and General Diseases, etc. 

Part ii. — Diseases of the Respiratory System, Circulatory 

System and Nervous System ; Diseases of the Blood, etc. 

Tanner's Index of Diseases, and Their Treatment. Cloth, 3.00 
"This work has won for itself a reputation. ... It is, in 

truth, what its Title indicates." — N. Y. Medical Record. 

PRESCRIPTION BOOKS. 

Wythe's Dose and Symptom Book. Containing the Doses 
and Uses of all the principal Articles of the Materia Medica, etc. 
Seventeenth Edition. Completely Revised and Rewritten. Just 
Ready. 32mo. Cloth, 1.00; Pocket-book style, 1.25 

Pereira's Physician's Prescription Book. Containing Lists 
of Terms, Phrases, Contractions and Abbreviations used in 
Prescriptions Explanatory Notes, Grammatical Construction of 
Prescriptions, etc., etc. By Professor Jonathan Pereira, m.d. 
Sixteenth Edition. 32mo. Cloth, 1.00; Pocket-book style, 1.25 

■&g=* See pages 2 to 5 for list of Neiv Manuals. 



STUDENTS' TEXT-BOOKS AND MANUALS. 18 

PHARMACY. 

Stewart's Compend of Pharmacy. Based upon Remington's 
Text-Book of Pharmacy. Second Edition, Revised. 

Cloth, i.oo ; Interleaved for Notes, 1.25 

SKIN DISEASES. 

Anderson, (McCall) Skin Diseases. A complete Text-Book, 

with Colored Plates and numerous Wood Engravings. 8vo. 

Just Ready. Cloth, 4.50; Leather, 5.50 

" We welcome Dr. Anderson's work not only as a friend, but as 

a benefactor to the profession, because the author has stricken off 

mediaeval shackles of insuperable nomenclature and made crooked 

ways straight in the diagnosis and treatment of this hitherto but 

little understood class of diseases. The chapter on Eczema is 

alone worth the price of the book." — Nashville Medical News. 

" Worthy its distinguished author in every respect ; a work whose 
practical value commends it not only to the practitioner and stu- 
dent of medicine, but also to the dermatologist."— James Nevens 
Hyde, m.d., Proj. oj Skin and Venereal Diseases, Rush Medical 
College, Chicago. 

Van Harlingen on Skin Diseases. A Handbook of the Dis- 
eases of the Skin, their Diagnosis and Treatment (arranged alpha- 
betically). By Arthur Van Harlingen, m.d., Clinical Lecturer 
on Dermatology, Jefferson Medical College; Prof, of Diseases of 
the Skin in the Philadelphia Polyclinic. 2d Edition. Enlarged. 
With colored and other plates and illustrations. 12010. Cloth, 2.50 
Bulkley. The Skin in Health and Disease. By L. Duncan 
Bulkley, Physician to theN. Y. Hospital. Illus. Cloth, .50 

SURGERY. 

Jacobson. Operations in Surgery. A Systematic Handbook 
for Physicians, Students and Hospital Surgeons. By W. H. A. 
Jacobson, b.a., Oxon. f.r.c.s. Eng. ; Ass't Surgeon Guy's Hos- 
pital ; Surgeon at Royal Hospital for Children and Women, etc. 
With 199 finely printed illustrations. 1006 pages. 8vo. 

Cloth. $5.00; Leather, 56.00 

Heath's Minor Surgery, and Bandaging. Ninth Edition. 142 
Illustrations. 60 Formulae and Diet Lists. Cloth, 2.00 

Horwitz's Compend of Surgery, including Minor Surgery, 
Amputations, Fractures, Dislocations, Surgical Diseases, and the 
Latest Antiseptic Rules, etc., with Differential Diagnosis and 
Treatment. By Orville Hokwitz, b.s., m.d., Demonstrator of 
Anatomy, Jefferson Medical College ; Chief, Out- Patient Surgi- 
cal Department, Jefferson Medical College Hospital. 3d edition. 
Very much Enlarged and Rearranged. 91 Illustrations and 
77 Formulae. i2mo. No. o ? Quiz- Compend ? Series. 

Cloth, 1.00 ; Interleaved for the addition of Notes, 1.25. 

Pye's Surgical Handicraft. A Manual of Surgical Manipula- 
tions, Minor Surgery, Bandaging, Dressing, etc., etc. With 
special chapters on Aural Surgery, Extraction of Teeth, Anaes- 
thetics, etc. 208 Illustrations. 8vo. Cloth, 5.00 

Swain's Surgical Emergencies. New Edition. Illus. Go., 1.50 

O" See pages 13 and ibjor list cf ? Quiz-Commends f 



14 STUDENTS' TEXT-BOOKS AND MANUALS. 

Surgery: — Continued. ' 
Walsham. Manual of Practical Surgery. For Students and 
Physicians. By Wm. J. Walsham, m.d., f.r c.s., Asst. Surg, 
to, and Dem. of Practical Surg, in, St. Bartholomew's Hospital, 
Surgeon to Metropolitan Free Hospital, London. With 236 
Engravings. See Page 2. Cloth, 3.00; Leather, 3.50 

THROAT. 

Mackenzie. Diseases of the GEsophagus, Nose and Naso- 
pharynx. By Sir Morell Mackenzie, m.d., Senior Physician to 
the Hospital for Diseases of the Chest and Throat ; Lecturer 
on Diseases of the Throat at the London Hospital, etc., with 
Formulae and 93 Illustrations. Being Vol. 11, complete in itself, 
of Dr. Mackenzie's text-book on the Throat and Nose. 

Cloth, 3.00; Leather, 4.00 
" It is both practical and learned ; abundantly and well illustrated ; 
its descriptions of disease are graphic and the diagnosis theb*twe 
have anywhere seen." — Philadelphia Medical Times. 

Cohen. The Throat and Voice. Illustrated. Cloth, .50 

James. Sore Throat. Its Nature, Varieties and Treatment. 

12010. Illustrated. Paper cover, .75 ; Cloth, 1.25 

URINE, URINARY ORGANS, ETC. 

Acton. The Reproductive Organs. In Childhood, Youth, 
Adult Life and Old Age. Seventh Edition. Cloth, 2.00 

Beale. Urinary and Renal Diseases and Calculous Disorders. 
Hints on Diagnosis and Treatment. i2mo. Cloth, 1.75 

Holland. The Urine, and Common Poisons and The 
Milk. Chemical and Microscopical, for Laboratory Use. Illus- 
trated. Third Edition. i2mo. Interleaved. Cloth, 1.00 

Ralfe. Kidney Diseases and Urinary Derangements. 42 Illus- 
trations. i2mo. 572 pages. Cloth, 2.75 

Legg. On the Urine. A Practical Guide. 6th Ed. Cloth, .75 

Marshall and Smith. On the Urine. The Chemical Analysis of 
the Urine. By John Marshall, m.d., Chemical Laboratory, Univ. 
of Penna ; and Prof. E. F. Smith, ph.d. Col. Plates. Cloth, 1.00 

Thompson. Diseases of the Urinary Organs. Eighth 
London Edition. Illustrated. Cloth, 3.50 

Tyson. On the Urine. A Practical Guide to the Examination 
of Urine. With Colored Plates and Wood Engravings. 6th Ed. 
Enlarged. i2mo. Cloth, 1.50 

Bright's Disease and Diabetes. Illus. Cloth, 3.50 

Van Niiys, Urine Analysis. Illus. Cloth, 2.00 

VENEREAL DISEASES. 

Hill and Cooper. Student's Manual of Venereal Diseases, 
with Formulae. Fourth Edition. i2mo. Cloth, 1.00 

Durkee. On Gonorrhoea and Syphilis. Illus. Cloth, 3.50 
4®=" See pages 15 and 16 for list of ? Quiz-Compends ? 



NEW AND REVISED EDITIONS. 

PQUIZ-COMPENDS? 

The Best Compends for Students' Use 
in the Quiz Class, and when Pre- 
paring for Examinations. 

Compiled hi accordance with the latest teachings of promi- 
nent lecturers and the most popular Text-books. 

They form a most complete, practical and exhaustive 
set of manuals, containing information nowhere else col- 
lected in such a condensed, practical shape. Thoroughly 
up to the times in every respect, containing many new 
prescriptions and formulae, and over two hundred and 
thirty illustrations, many of which have been drawn and 
engraved specially for this series. The authors have had 
large experience as quiz-masters and attaches of colleges, 
with exceptional opportunities for noting the most recent 
advances and methods. The arrangement of the subjects, 
illustrations, types, etc., are all of the most approved 
form, and the size of the books is such that they may be 
easily carried in the pocket. They are constantly being 
revised, so as to include the latest and best teachings, and 
can be used by students of any college of medicine, den- 
tistry or pharmacy. 

Cloth, each $1.00. Interleaved for Notes, $1.25. 

No. 1. HUMAN ANATOMY, "Based upon Gray." Fourth 
Edition, including Visceral Anatomy, formerly published 
separately. Over 100 Illustrations. By Samuel O. L. 
Potter, m.a., m.d., late A. A. Surgeon U. S. Army. Professor 
of Practice, Cooper Medical College, San Francisco. 
Nos.2and3. PRACTICE OF MEDICINE. Third Edition. 
By Daniel E. Hughes, m.d., Demonstrator of Clinical Medi- 
cine in Jefferson Medical College, Philadelphia. In two parts. 
Part I. — Continued, Eruptive and Periodical Fevers, Diseases 
of the Stomach, Intestines, Peritoneum, Biliary Passages, Liver, 
Kidneys, etc. (including Tests for Urine), General Diseases, etc. 

Part II. — Diseases of the Respiratory System (including Phy- 
sical Diagnosis), Circulatory System and Nervous System; Dis- 
eases of the Blood, etc. 

*** These little books can be regarded as a full set of notes upon 
the Practice of Medicine, containing the Synonyms, Definitions, 
Causes, Symptoms, Prognosis, Diagnosis, Treatment, etc., of each 
disease, and including a number of prescriptions hitherto unpub- 
lished. 

(cvhr.) 



BLAKISTON'S ? QUIZ-COMPENDS ? 

Continued. 
Bound in Cloth, $1.00. Interleaved, for Notes, $1.25 

No. 4. PHYSIOLOGY, including Embryology. Fifth 
Edition. By Albert P. Brubaker, m.d., Prof, of Physiology, 
Penn'a College of Dental Surgery ; Demonstrator of Physiology 
In Jefferson Medical College, Philadelphia. Revised, Enlarged 
and Illustrated. 

No. 5. OBSTETRICS. Illustrated. Fourth Edition. By 
Henky G. Landis, m.d., Prof, of Obstetrics and Diseases of 
Women, in Starling Medical College, Columbus, O. Revised 
Edition. New Illustrations. 

No. 6. MATERIA MEDICA, THERAPEUTICS AND 
PRESCRIPTION WRITING. Fifth Revised Edition. 
With especial Reference to the Physiological Action of Drugs, 
and a complete article on Prescription Writing. Based on the 
Last Revision of the U. S. Pharmacopoeia, and including many 
unofficinal remedies. By Samuel O. L. Potter, m.a., m.d., 
late A. A. Surg. U. S. Army ; Prof, of Practice, Cooper Medical 
College, San Francisco. Improved and Enlarged, with Index. 

No. 7. GYN/ECOLOGY. A Compend of Diseases of Women. 
By Henry Morris, m.d., Demonstrator of Obstetrics, Jefferson 
Medical College, Philadelphia. 

No. 8. DISEASES OF THE EYE AND REFRACTION, 
including Treatment and Surgery. By L. Webster Fox, m.d., 
Chief Clinical Assistant Ophthalmological Dept., Jefferson Med- 
ical College, etc., and Geo. M. Gould, m.d. 71 Illustrations, 39 
Formulae. Second Enlarged and improved Edition. Index. 

No. 9. SURGERY. Illustrated. Third Edition. Including 
Fractures, Wounds, Dislocations, Sprains, Amputations and 
other operations; Inflammation, Suppuration, Ulcers, Syphilis, 
Tumors, Shock, etc. Diseases of the Spine, Ear, Bladder, Tes- 
ticles, Anus, and other Surgical Diseases. By Orville Horwitz, 
a.m., m.d., Demonstrator of Anatomy, Jefferson Medical Col- 
lege. Revised and Enlarged. 77 Formulae and 91 Illustrations. 

No. 10. CHEMISTRY. Inorganic and Organic. For Medical 
and Dental Students. Including Urinary Analysis and Medical 
Chemistry. By Henry Leffmann, m.d., Prof, of Chemistry in 
Penn'a College of Dental Surgery, Phila. A new Edition, Revised 
and Rewritten, with Index. 

No. 11. PHARMACY. Based upon " Remington's Text-book 
of Pharmacy." By F. E. Stewart, m.d., ph. g., Quiz-Master 
at Philadelphia College of Pharmacy. Second Edition, Revised. 

Bound in Cloth, $1. Interleaved, for the Addition of Notes, $1.25. 

g^ tt> These books are constantly revised to keep up with 
the latest teachings and discoveries, so that they contain 
all the new methods and principles. No series of books 
are so complete in detail, concise in language, or so well 
printed and bound. Each one forms a complete set of 
notes upon the subject under consideration. 



